3 Tier - ConnectiCare

Transcription

Drug List – 3 Tiers
for employer-sponsored plans
2016
This document is the complete ConnectiCare pharmacy drug list that is covered by your employersponsored plan with three-tier drug benefits. This drug list, also known as a formulary, was last
updated on September 1, 2016. The list is subject to change as new drugs come into market or are
removed from the market because the U.S. Food and Drug Administration (FDA) has determined a
drug is unsafe or if the drug’s manufacturer removes the drug from the market. Please check the
Pharmacy Center on connecticare.com for the most up-to-date drug list covered by your plan.
What is a drug list?
It’s a list of covered drugs — both generic and brand-name drugs — selected by ConnectiCare in
consultation with a team of health care providers. It includes the prescription therapies believed to
be a necessary part of a quality treatment program. ConnectiCare will generally cover the drugs
listed in our formulary as long as the drug is medically necessary, the prescription is filled at a
ConnectiCare network pharmacy and other plan rules are followed.
How do I use the formulary?
To search for your drug within the formulary, please refer to the:
 Table of Contents on page 1 and look for your drug under the therapeutic class sections; or
 Index, which starts on page 108, and look for your drug and the corresponding page.
This formulary will tell you what tier your drug is in. A drug tier is a group of medications
included within a similar price range. In most cases, the lower the drug tier, the less you pay.
Tier
Tier 0
Tier 1
Tier 2
Tier 3
What drugs are included
Drugs covered under health care reform
Generic drugs
Preferred brand-name drugs
Non-preferred brand name drugs
What’s the cost-share
No cost-share
Lowest cost-share $
Mid-level cost-share $$
Highest cost-share $$$
If your doctor prescribes a drug that is not listed, you may have to pay more out of pocket for the
drug. If it’s appropriate, ask your doctor about a generic medication or a more affordable
alternative that is included in the drug list.
What are generic drugs and brand-name drugs?
A generic drug is approved by the FDA as having the same active ingredient as the brand-name
drug. Generally, generic drugs cost less than brand-name drugs.
This formulary differentiates between the two kinds of drugs by how they are presented on the list:
 generic drugs are italicized and spelled out in lowercase letters
 brand-name drugs are not italicized and spelled out in uppercase letters
Under your plan, a pharmacist will fill a generic drug for a prescription whenever a generic is
available. For the most part, this will happen even if your prescription is written for a brandname drug. But you or your doctor can specifically instruct the pharmacist to fill the prescription
with a brand-name drug. When this happens, you may pay more and the cost will depend on your
plan benefits. Please refer to your plan documents for details.
Are there any limitations on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These may include:
 Preauthorization (PA): ConnectiCare requires you or your doctor to get preauthorization
for certain drugs. This means that you or your doctor will need to get approval from us
before you fill your prescriptions. If you don’t get approval, the drug may not be covered
and you may be responsible for the entire cost of the medication.
 Quantity limits (QL): For certain medications, ConnectiCare limits the amount of the
drug that we will cover. For example, ConnectiCare covers Maxalt (or its generic version,
rizatriptan) for 9 tablets per 30 days. This may be in addition to a standard one-month or
three-month supply.
 Step therapy (ST): In some cases, ConnectiCare requires you to first try certain drugs to
treat your medical condition before we will cover another drug for that condition. For
example, if Drug A and Drug B both treat your medical condition, we may not cover Drug
B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
Other things you may need to know as you use this formulary:
 Affordable Care Act (ACA): This refers to the federal health care reform and what drugs
are covered under the law as having no cost-share. This means the drugs — as long as they
are prescribed under the preventive care guidelines of the Affordable Care Act — are free
so you will not have to pay any copayment, coinsurance or anything toward your
deductible.
 Limited Availability (LA): This represents specialty drugs, which must be filled by
ConnectiCare’s preferred specialty pharmacy and are limited to a 30-day supply. These
drugs are prescription medications used to treat complex conditions and often require
special storage, handling and close monitoring by you, your doctor or pharmacist.
 Over the counter (OTC): ConnectiCare does not cover over-the-counter drugs unless they
are listed in this formulary and have been prescribed by a doctor.
The formulary will note which drugs have any additional requirements or limits. You can also
get more information about the restrictions applied to specific covered drugs by visiting
connecticare.com.
Do you speak another language and need assistance?
If you speak a foreign language, translation and interpretation services are available to assist you.
You may obtain interpreter services for verbal communications with us by calling 1-800-251-7722.
Si usted habla un idioma extranjero, la traducción y la interpretación servicios están disponibles
para ayudarle. Usted puede obtener servicios de intérprete para las comunicaciones verbales con
nosotros llamando al 1-800-251-7722.
Rev. 9.1.16
Table of Contents
Anti - Infectives .................................................................................................................................................... 3
Antineoplastic & Immunosuppressant Drugs .................................................................................................... 11
Autonomic & Cns Drugs, Neurology & Psych .................................................................................................. 16
Cardiovascular, Hypertension & Lipids ............................................................................................................. 30
Dermatologicals/Topical Therapy ...................................................................................................................... 38
Diagnostics & Miscellaneous Agents ................................................................................................................ 47
Ear, Nose & Throat Medications........................................................................................................................ 49
Endocrine/Diabetes ............................................................................................................................................ 50
Gastroenterology ................................................................................................................................................ 69
Immunology, Vaccines & Biotechnology .......................................................................................................... 75
Musculoskeletal & Rheumatology ..................................................................................................................... 80
Obstetrics & Gynecology ................................................................................................................................... 81
Ophthalmology ................................................................................................................................................... 87
Respiratory, Allergy, Cough & Cold ................................................................................................................. 90
Urologicals ......................................................................................................................................................... 95
Vitamins, Hematinics & Electrolytes ................................................................................................................. 96
Index ................................................................................................................................................................. 108
1
List of Abbreviations
ACA: Affordable Care Act.
LA: Limited Availability. This prescription may be available only at certain pharmacies. For more
information, please call Customer Service.
OTC: Over the Counter. An OTC drug is a non-prescription drug.
PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs.
This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we
may not cover the drug.
QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.
ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical
condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat
your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for
you, we will then cover Drug B.
2
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Anti - Infectives
NOXAFIL ORAL
3
Antifungal Agents
nystatin
1
Restrictions /
Limits
ABELCET
3
PA
ONMEL
3
PA
AMBISOME
3
PA
ORAVIG
3
ST; QL
amphotericin b
1
PA
SPORANOX
3
PA; QL
ANCOBON
3
SPORANOX
PULSEPAK
3
PA; QL
CANCIDAS
3
terbinafine hcl
1
clotrimazole
1
TERBINEX
3
CRESEMBA
INTRAVENOUS
3
PA
VFEND
3
QL
CRESEMBA ORAL
3
QL
VFEND IV
3
PA
DIFLUCAN
3
voriconazole
intravenous
1
PA
ERAXIS(WATER
DILUENT)
3
voriconazole oral
1
QL
fluconazole
1
fluconazole in
dextrose(iso-o)
1
flucytosine
1
griseofulvin
microsize
1
griseofulvin
ultramicrosize
1
GRIS-PEG
(ULTRAMICROSIZ
E)
3
itraconazole
1
ketoconazole
1
LAMISIL ORAL
GRANULES IN
PACKET
3
LAMISIL ORAL
TABLET
3
MYCAMINE
3
NOXAFIL
INTRAVENOUS
3
PA
PA
Antivirals
abacavir
1
abacavirlamivudinezidovudine
1
acyclovir
1
acyclovir sodium
1
adefovir
1
amantadine hcl
1
APTIVUS
3
ATRIPLA
3
BARACLUDE
3
cidofovir
1
COMBIVIR
3
COMPLERA
3
CRIXIVAN
2
PA
CYTOVENE
3
PA; LA
PA
DAKLINZA
3
PA; LA
DESCOVY
3
PA
PA; QL
PA
PA
PA
This Formulary List is subject to change.
3
Drug Name
Tier
didanosine
Restrictions /
Limits
Drug Name
Tier
1
lamivudine
1
EDURANT
3
1
EMTRIVA
2
lamivudinezidovudine
entecavir
1
LEXIVA
3
EPCLUSA
3
nevirapine
1
EPIVIR
3
NORVIR
2
EPIVIR HBV
ORAL SOLUTION
2
ODEFSEY
3
OLYSIO
2
EPIVIR HBV
ORAL TABLET
3
PREZCOBIX
3
PREZISTA
3
EPZICOM
3
RAPIVAB
3
PA
EVOTAZ
3
2
QL
famciclovir
1
RELENZA
DISKHALER
FAMVIR
3
RESCRIPTOR
2
FLUMADINE
3
3
foscarnet
1
PA
RETROVIR
INTRAVENOUS
FOSCAVIR
3
PA
RETROVIR ORAL
3
FUZEON
3
PA; LA
REYATAZ ORAL
CAPSULE
2
ganciclovir sodium
1
PA; LA
3
HARVONI
3
REYATAZ ORAL
POWDER IN
PACKET
3
GENVOYA
HEPSERA
3
rimantadine
1
INCIVEK
2
SELZENTRY
3
INTELENCE
3
SITAVIG
3
PA
INVIRASE
2
SOVALDI
2
PA; LA
ISENTRESS ORAL
POWDER IN
PACKET
3
stavudine
1
STRIBILD
3
SUSTIVA
2
ISENTRESS ORAL
TABLET
2
TAMIFLU
2
QL
ISENTRESS ORAL
TABLET,CHEWAB
LE
2
TECHNIVIE
3
PA; LA
TIVICAY
3
TRIUMEQ
3
KALETRA
2
TRIZIVIR
3
PA; LA
PA; LA; QL
PA
4
Restrictions /
Limits
PA; LA
PA; LA
Drug Name
Tier
Restrictions /
Limits
TRUVADA
3
CEDAX
3
TYBOST
3
cefaclor
1
TYZEKA
3
cefadroxil
1
valacyclovir
1
cefazolin
1
VALCYTE ORAL
RECON SOLN
3
1
VALCYTE ORAL
TABLET
3
QL
cefazolin in dextrose
(iso-os) intravenous
piggyback 1 gram/50
ml, 2 gram/50 ml
valganciclovir
1
QL
3
VALTREX
3
VICTRELIS
2
VIDEX 2 GRAM
PEDIATRIC
2
CEFAZOLIN IN
DEXTROSE (ISOOS)
INTRAVENOUS
PIGGYBACK 2
GRAM/100 ML
cefdinir
1
VIDEX EC
3
cefditoren pivoxil
1
VIEKIRA PAK
3
cefepime
1
VIRACEPT
2
3
CEFEPIME IN
DEXTROSE 5 %
3
VIRAMUNE
VIRAMUNE XR
3
1
PA
VIRAZOLE
3
cefepime in
dextrose,iso-osm
VIREAD ORAL
POWDER
3
cefixime
1
QL
CEFOTAN
3
PA
VIREAD ORAL
TABLET
2
cefotaxime
1
PA
cefotetan
1
PA
VITEKTA
3
3
PA
ZEPATIER
2
ZERIT
3
CEFOTETAN IN
DEXTROSE, ISOOSM
ZIAGEN ORAL
SOLUTION
2
cefoxitin
1
PA
1
PA
ZIAGEN ORAL
TABLET
3
cefoxitin in dextrose,
iso-osm
cefpodoxime
1
QL
zidovudine
1
cefprozil
1
ZOVIRAX
3
ceftazidime
1
PA
CEFTAZIDIME IN
D5W
3
PA
PA; LA
PA; LA; QL
PA
PA; LA
Cephalosporins
AVYCAZ
3
PA
Drug Name
Tier
Restrictions /
Limits
PA
5
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
ceftibuten
1
TEFLARO
3
PA
CEFTIN
3
ZERBAXA
3
PA
ceftriaxone in
dextrose,iso-os
1
PA
ZINACEF
3
PA
3
PA
ceftriaxone injection
recon soln 1 gram,
10 gram, 2 gram,
250 mg, 500 mg
1
PA
ZINACEF IN
STERILE WATER
CEFTRIAXONE
INJECTION
RECON SOLN 100
GRAM
3
ceftriaxone
intravenous
1
cefuroxime axetil
1
cefuroxime sodium
injection recon soln
1.5 gram, 750 mg
1
CEFUROXIME
SODIUM
INJECTION
RECON SOLN 75
GRAM
3
cefuroxime sodium
intravenous
1
cephalexin
1
FORTAZ
3
PA
FORTAZ IN
DEXTROSE 5 %
3
PA
KEFLEX
3
MAXIPIME
3
PA
MEFOXIN IN
DEXTROSE (ISOOSM)
3
PA
SPECTRACEF
3
SUPRAX
3
QL
TAZICEF
3
PA
Erythromycins & Other Macrolides
PA
PA
PA
PA
PA
6
azithromycin
intravenous
1
azithromycin oral
1
BIAXIN
3
clarithromycin
1
DIFICID
3
e.e.s. 400
1
E.E.S. GRANULES
3
ERYPED 200
2
ERYPED 400
2
ery-tab oral
tablet,delayed
release (dr/ec) 250
mg, 333 mg
1
ERY-TAB ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 500 MG
2
ERYTHROCIN
3
erythrocin (as
stearate)
1
erythromycin
1
erythromycin
ethylsuccinate
1
PCE
3
ZITHROMAX
INTRAVENOUS
3
ZITHROMAX
ORAL
3
PA
PA; QL
PA
PA
Drug Name
ZMAX
Tier
Restrictions /
Limits
3
Miscellaneous Antiinfectives
Drug Name
Tier
CLEOCIN ORAL
RECON SOLN
3
CLIN SINGLE USE
3
clindamycin hcl
1
clindamycin in 5 %
dextrose
1
1
Restrictions /
Limits
PA
ALBENZA
3
ALINIA
3
amikacin
1
atovaquone
1
PA
atovaquoneproguanil
1
PA
clindamycin
palmitate hcl
3
PA
clindamycin
pediatric
1
AZACTAM
AZACTAM IN
DEXTROSE (ISOOSM)
3
PA
clindamycin
phosphate
1
PA
COARTEM
3
PA
aztreonam
1
PA
1
PA
baciim
1
PA
colistin
(colistimethate na)
bacitracin
1
PA
3
PA
BETHKIS
3
COLY-MYCIN M
PARENTERAL
BILTRICIDE
3
CYCLOSERINE
3
CAPASTAT
3
PA
DALVANCE
3
CAYSTON
3
PA
dapsone
1
chloramphenicol sod
succinate
1
PA
DARAPRIM
2
PA
DORIBAX
3
PA
chloroquine
phosphate
1
EMVERM
3
ethambutol
1
CLEOCIN IN 5 %
DEXTROSE
3
PA
FLAGYL
3
CLEOCIN
INJECTION
3
PA
FLAGYL ER
3
gentamicin
1
CLEOCIN
INTRAVENOUS
3
1
CLEOCIN ORAL
CAPSULE 150 MG,
300 MG
3
CLEOCIN ORAL
CAPSULE 75 MG
2
gentamicin in nacl
(iso-osm)
intravenous
piggyback 100
mg/100 ml, 60 mg/50
ml, 70 mg/50 ml, 80
mg/100 ml, 80 mg/50
ml, 90 mg/100 ml
QL
PA
PA
PA
PA
7
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
meropenem
1
PA
MERREM
3
PA
metro i.v.
1
PA
metronidazole
1
metronidazole in
nacl (iso-os)
1
MYAMBUTOL
3
MYCOBUTIN
3
NEBUPENT
3
neomycin
1
ORBACTIV
3
paromomycin
1
PASER
3
PENTAM
3
GENTAMICIN IN
NACL (ISO-OSM)
INTRAVENOUS
PIGGYBACK 100
MG/50 ML, 120
MG/100 ML
3
gentamicin sulfate
(ped) (pf)
1
gentamicin sulfate
(pf) intravenous
solution 100 mg/10
ml
1
GENTAMICIN
SULFATE (PF)
INTRAVENOUS
SOLUTION 60
MG/6 ML
3
hydroxychloroquine
1
imipenem-cilastatin
1
PA
PLAQUENIL
3
IMPAVIDO
3
PA
polymyxin b sulfate
1
INVANZ
3
PA
PRIFTIN
2
isoniazid injection
1
PA
PRIMAQUINE
2
isoniazid oral
1
PRIMAXIN IV
3
ivermectin
1
pyrazinamide
1
kanamycin
1
QUALAQUIN
3
KETEK
3
quinine sulfate
1
KITABIS PAK
3
rifabutin
1
linezolid intravenous
1
PA
3
linezolid oral
1
QL
RIFADIN
INTRAVENOUS
linezolid-0.9%
sodium chloride
1
PA
RIFADIN ORAL
3
RIFAMATE
3
MALARONE
3
PA
rifampin intravenous
1
MALARONE
PEDIATRIC
3
PA
rifampin oral
1
RIFATER
3
mefloquine
1
PA
SIRTURO
3
MEPRON
3
PA
SIVEXTRO
INTRAVENOUS
3
8
Restrictions /
Limits
PA
PA
PA
PA
PA
PA
PA
PA
PA
Drug Name
Tier
Restrictions /
Limits
SIVEXTRO ORAL
3
STREPTOMYCIN
3
STROMECTOL
3
TINDAMAX
3
QL
tinidazole
1
QL
TOBI
3
TOBI PODHALER
3
tobramycin in 0.225
% nacl
1
tobramycin in 0.9 %
nacl
1
tobramycin sulfate
1
TRECATOR
3
TYGACIL
3
XIFAXAN
3
YODOXIN
3
ZYVOX
INTRAVENOUS
3
ZYVOX ORAL
3
PA
PA
PA
QL
Penicillins
Drug Name
Tier
Restrictions /
Limits
ampicillin
1
ampicillin sodium
1
PA
ampicillin-sulbactam
1
PA
AUGMENTIN ES600
3
AUGMENTIN
ORAL
SUSPENSION FOR
RECONSTITUTIO
N 125-31.25 MG/5
ML
2
AUGMENTIN
ORAL
SUSPENSION FOR
RECONSTITUTIO
N 250-62.5 MG/5
ML
3
AUGMENTIN
ORAL TABLET
3
AUGMENTIN XR
3
BICILLIN C-R
3
BICILLIN L-A
3
dicloxacillin
1
MOXATAG
3
nafcillin
1
PA
nafcillin in dextrose
iso-osm
1
PA
oxacillin
1
PA
oxacillin in
dextrose(iso-osm)
1
PA
PENICILLIN G
POT IN
DEXTROSE
3
PA
PA
amoxicillin oral
capsule
1
amoxicillin oral
suspension for
reconstitution
1
amoxicillin oral
tablet
1
AMOXICILLIN
ORAL TABLET,
ER MULTIPHASE
24 HR
3
amoxicillin oral
tablet,chewable
1
penicillin g
potassium
1
PA
amoxicillin-pot
clavulanate
1
penicillin g procaine
1
PA
penicillin g sodium
1
PA
9
Drug Name
Tier
Restrictions /
Limits
penicillin v
potassium
1
pfizerpen-g
1
PA
piperacillintazobactam
1
PA
UNASYN
3
PA
Sulfa's & Related Agents
ZOSYN
3
PA
BACTRIM
3
ZOSYN IN
DEXTROSE (ISOOSM)
3
PA
BACTRIM DS
3
sulfadiazine
1
sulfamethoxazoletrimethoprim
intravenous
1
sulfamethoxazoletrimethoprim oral
1
sulfatrim
1
Quinolones
AVELOX
3
AVELOX ABC
PACK
2
AVELOX IN NACL
(ISO-OSMOTIC)
3
CIPRO
3
CIPRO IN D5W
3
CIPRO XR
3
ciprofloxacin
1
ciprofloxacin
(mixture)
1
ciprofloxacin hcl
1
ciprofloxacin in 5 %
dextrose
1
ciprofloxacin lactate
1
FACTIVE
3
LEVAQUIN
3
levofloxacin in d5w
1
PA
levofloxacin
intravenous
1
PA
levofloxacin oral
1
moxifloxacin
1
PA
Drug Name
Tier
MOXIFLOXACINSOD.ACE,SULWATER
3
NOROXIN
3
ofloxacin
1
Restrictions /
Limits
PA
PA
Tetracyclines
PA
PA
PA
10
ACTICLATE
3
PA
ADOXA
3
PA
avidoxy
1
AVIDOXY DK
3
demeclocycline
1
DORYX
3
PA
DORYX MPC
3
PA
doxy-100
1
PA
doxycycline hyclate
1
doxycycline
monohydrate oral
capsule
1
DOXYCYCLINE
MONOHYDRATE
ORAL
CAPSULE,IR DELAY
REL,BIPHASE
3
PA
PA
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
MACROBID
3
MACRODANTIN
3
methenamine
hippurate
1
methenamine
mandelate
1
doxycycline
monohydrate oral
suspension for
reconstitution
1
doxycycline
monohydrate oral
tablet
1
MINOCIN
3
PA
MONUROL
3
MINOCIN KIT
WITH WIPES
3
PA
nitrofurantoin
1
1
minocycline oral
capsule
1
nitrofurantoin
macrocrystal
1
nitrofurantoin
monohyd/m-cryst
1
minocycline oral
tablet
PRIMSOL
3
minocycline oral
tablet extended
release 24 hr
1
trimethoprim
1
mondoxyne nl
1
MONODOX
3
morgidox
1
MORGIDOX 2X100
PA
Restrictions /
Limits
QL
Vancomycin
VANCOCIN
3
vancomycin
1
3
3
VANCOMYCIN IN
DEXTROSE 5 %
ocudox
1
VIBATIV
3
ORACEA
3
PA
SOLODYN
3
PA
tetracycline
1
Adjunctive Agents
VIBRAMYCIN
ORAL CAPSULE
3
amifostine
crystalline
1
PA; LA
VIBRAMYCIN
ORAL
SUSPENSION FOR
RECONSTITUTIO
N
3
calcium folinate
(leucovorin)
1
PA; LA
dexrazoxane hcl
1
PA; LA
ELITEK
3
PA; LA
VIBRAMYCIN
ORAL SYRUP
2
KEPIVANCE
3
PA; LA
leucovorin calcium
injection
1
PA; LA
leucovorin calcium
oral
1
PA
Urinary Tract Agents
FURADANTIN
3
HIPREX
3
PA
Antineoplastic &
Immunosuppressant Drugs
11
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
mesna
1
PA; LA
azathioprine sodium
1
PA
MESNEX
INTRAVENOUS
3
PA; LA
BELEODAQ
3
PA
BENDEKA
3
PA; LA
MESNEX ORAL
3
bexarotene
1
PA
TOTECT
3
PA; LA
bicalutamide
1
VISTOGARD
3
PA
BICNU
3
PA; LA
VORAXAZE
3
PA
bleomycin
1
PA; LA
XGEVA
3
QL
BLINCYTO
3
PA
ZINECARD (AS
HCL)
3
PA; LA
BOSULIF
3
PA; LA; QL
BUSULFEX
3
PA; LA
CABOMETYX
3
PA; LA
Antineoplastic &
Immunosuppressant Drugs
ABRAXANE
3
PA; LA
CAMPATH
3
PA
ADCETRIS
3
PA
CAMPTOSAR
3
PA; LA
adrucil
1
PA; LA
capecitabine
1
PA; LA
AFINITOR
3
PA; LA
CAPRELSA
3
PA; QL
AFINITOR
DISPERZ
3
PA; LA
carboplatin
1
PA; LA
CASODEX
3
ALECENSA
3
PA; LA
CELLCEPT
3
ALIMTA
3
PA; LA
3
PA; LA
ALKERAN
INTRAVENOUS
3
PA; LA
CELLCEPT
INTRAVENOUS
cisplatin
1
PA; LA
ALKERAN ORAL
2
cladribine
1
PA; LA
anastrozole
1
CLOLAR
3
PA; LA
ARIMIDEX
3
COMETRIQ
3
PA
AROMASIN
3
COSMEGEN
3
PA; LA
ARRANON
3
PA; LA
COTELLIC
3
PA; LA
ARZERRA
3
PA; LA
1
PA; LA
ASTAGRAF XL
3
cyclophosphamide
intravenous
AVASTIN
3
PA; LA
cyclophosphamide
oral
1
azacitidine
1
PA; LA
3
cyclosporine
intravenous
1
AZASAN
azathioprine
1
12
PA; LA
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
cyclosporine
modified
1
cyclosporine oral
1
CYRAMZA
3
PA
cytarabine
1
PA; LA
cytarabine (pf)
1
PA; LA
dacarbazine
1
PA; LA
DACOGEN
3
PA; LA
DARZALEX
3
PA; LA
daunorubicin
1
PA; LA
decitabine
1
PA; LA
DOCEFREZ
3
PA; LA
docetaxel
1
PA; LA
DOXIL
3
PA; LA
doxorubicin
1
PA; LA
doxorubicin, pegliposomal
1
PA
DROXIA
2
ELIGARD
3
ELLENCE
3
EMCYT
3
EMPLICITI
3
FARESTON
2
FARYDAK
3
PA; LA
FASLODEX
3
PA
FEMARA
3
FIRMAGON KIT W
DILUENT
SYRINGE
3
PA
floxuridine
1
PA; LA
fludarabine
1
PA; LA
fluorouracil
1
PA; LA
flutamide
1
FOLOTYN
3
PA; LA
GAZYVA
3
PA; LA
gemcitabine
1
PA; LA
GEMZAR
3
PA; LA
gengraf
1
GILOTRIF
3
PA; LA; QL
GLEEVEC
3
PA; LA
LA
GLEOSTINE
3
PA; LA
GLIADEL WAFER
3
HALAVEN
3
PA; LA
HERCEPTIN
3
PA; LA
ENVARSUS XR
3
HEXALEN
3
epirubicin
1
PA; LA
HYCAMTIN
3
ERBITUX
3
PA; LA
HYDREA
3
ERIVEDGE
3
PA; LA; QL
hydroxyurea
1
ERWINAZE
3
PA; LA
IBRANCE
3
PA; LA; QL
ETOPOPHOS
3
PA; LA
ICLUSIG
3
PA
etoposide
intravenous
1
PA; LA
IDAMYCIN PFS
3
PA; LA
idarubicin
1
PA; LA
etoposide oral
1
IFEX
3
PA; LA
EVOMELA
3
ifosfamide
1
PA; LA
exemestane
1
PA; LA
PA
Restrictions /
Limits
PA; LA
13
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
LUPRON DEPOT
(6 MONTH)
3
LUPRON DEPOTPED
3
LUPRON DEPOTPED (3 MONTH)
3
Restrictions /
Limits
ifosfamide-mesna
1
PA; LA
imatinib
1
PA; LA
IMBRUVICA
3
PA; QL
IMLYGIC
3
PA; LA
IMURAN
3
INLYTA
3
PA; LA; QL
LYNPARZA
3
IODOPEN
3
PA
LYSODREN
3
IRESSA
3
PA
MARQIBO
3
irinotecan
intravenous solution
100 mg/5 ml, 40
mg/2 ml
1
PA; LA
MATULANE
2
MEGACE
3
MEGACE ES
3
irinotecan
500 mg/25 ml
1
megestrol
1
MEKINIST
3
PA; LA; QL
ISTODAX
3
PA; LA
melphalan hcl
1
PA; LA
IXEMPRA
3
PA; LA
mercaptopurine
1
JAKAFI
3
PA; LA; QL
methotrexate sodium
1
JEVTANA
3
PA; LA
methotrexate sodium
(pf)
1
KADCYLA
3
PA; LA
mitomycin
1
PA; LA
KEYTRUDA
3
PA
mitoxantrone
1
PA; LA
KYPROLIS
3
PA; LA
MUSTARGEN
3
PA; LA
LENVIMA
3
PA; LA
1
mycophenolate
mofetil
1
letrozole
LEUKERAN
2
1
leuprolide
1
mycophenolate
sodium
lipodox
1
PA; LA
MYFORTIC
3
LONSURF
3
PA; LA
MYLERAN
2
LUPRON DEPOT
3
NAVELBINE
3
LUPRON DEPOT
(3 MONTH)
3
NEORAL
3
NEXAVAR
3
LUPRON DEPOT
(4 MONTH)
3
NILANDRON
2
NINLARO
3
PA; LA
NIPENT
3
PA; LA
LA
14
PA
PA
PA; LA
PA; LA
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
3
PA; LA; QL
NULOJIX
3
PA; LA
octreotide acetate
1
PA
ODOMZO
3
PA; LA; QL
ONCASPAR
3
PA; LA
OPDIVO
3
PA
SANDOSTATIN
LAR DEPOT
INTRAMUSCULA
R
SUSPENSION,EXT
ENDED REL
RECON
oxaliplatin
1
PA; LA
SIGNIFOR
3
PA; LA
paclitaxel
1
PA; LA
SIGNIFOR LAR
3
PA; LA; QL
PERJETA
3
PA; LA
SIMULECT
3
PA; LA
PHOTOFRIN
3
PA; LA
sirolimus
1
PROGRAF
INTRAVENOUS
3
PA; LA
SOLTAMOX
0
ACA
PA
3
SOMATULINE
DEPOT
3
PROGRAF ORAL
PURIXAN
3
SPRYCEL
3
PA; LA
RAPAMUNE
ORAL SOLUTION
2
STIVARGA
3
PA; LA; QL
SUTENT
3
PA; LA; QL
RAPAMUNE
ORAL TABLET
3
SYLVANT
3
PA; LA
RHEUMATREX
3
SYNRIBO
3
PA
RITUXAN
3
PA; LA
TABLOID
2
SANDIMMUNE
INTRAVENOUS
3
PA
tacrolimus
1
TAFINLAR
3
PA; LA; QL
SANDIMMUNE
ORAL CAPSULE
3
TAGRISSO
3
PA; LA
tamoxifen
0
ACA
SANDIMMUNE
ORAL SOLUTION
2
TARCEVA
3
PA; LA; QL
SANDOSTATIN
3
PA
TARGRETIN
ORAL
3
PA
SANDOSTATIN
LAR DEPOT
INTRAMUSCULA
R KIT
3
PA; QL
TARGRETIN
TOPICAL
2
TASIGNA
3
PA; LA
TAXOTERE
3
PA; LA
TECENTRIQ
3
PA; LA
TEMODAR
3
PA; LA
temozolomide
1
PA; LA
TENIPOSIDE
3
15
Drug Name
Tier
Restrictions /
Limits
Drug Name
THALOMID
Tier
Restrictions /
Limits
3
PA; LA; QL
ZEVALIN (Y-90)
3
PA; LA
thiotepa
1
PA; LA
ZOLADEX
3
LA
toposar
1
PA; LA
ZOLINZA
3
PA; LA
topotecan
1
PA; LA
ZORTRESS
3
PA; LA
TORISEL
3
PA; LA
ZYDELIG
3
PA
TREANDA
3
PA; LA
ZYKADIA
3
PA; LA
TRELSTAR
3
PA
ZYTIGA
3
PA; LA; QL
tretinoin
(chemotherapy)
1
TREXALL
3
TRISENOX
3
PA; LA
TYKERB
3
PA; LA; QL
UNITUXIN
3
PA; LA
VECTIBIX
3
VELCADE
Autonomic & Cns Drugs, Neurology
& Psych
Anticonvulsants
APTIOM
3
BANZEL
3
BRIVIACT
INTRAVENOUS
3
PA; LA
3
PA; LA
BRIVIACT ORAL
3
VENCLEXTA
3
PA; LA
carbamazepine
1
VENCLEXTA
STARTING PACK
3
PA; LA
CARBATROL
3
CELONTIN
2
VIDAZA
3
PA; LA
CEREBYX
3
vinblastine
1
PA; LA
clonazepam
1
vincasar pfs
1
PA; LA
DEPACON
3
vincristine
1
PA; LA
DEPAKENE
3
vinorelbine
1
PA; LA
DEPAKOTE
3
VOTRIENT
3
PA; LA
DEPAKOTE ER
3
XALKORI
3
PA; LA; QL
3
PA; LA
DEPAKOTE
SPRINKLES
3
XELODA
XTANDI
3
PA; LA; QL
DIASTAT
2
YERVOY
3
PA; LA
3
YONDELIS
3
PA; LA
DIASTAT
ACUDIAL
ZALTRAP
3
PA; LA
diazepam
1
ZANOSAR
3
PA; LA
DILANTIN
2
ZELBORAF
3
PA; LA; QL
DILANTIN
EXTENDED
3
16
PA
PA
PA
Drug Name
Tier
DILANTIN
INFATABS
3
DILANTIN-125
3
divalproex
1
epitol
1
EQUETRO
3
ethosuximide
1
felbamate
1
FELBATOL
3
fosphenytoin
1
FYCOMPA
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
LAMICTAL ODT
STARTER
(ORANGE)
3
LAMICTAL
STARTER (BLUE)
KIT
3
PA
LAMICTAL
STARTER
(GREEN) KIT
3
PA
LAMICTAL
STARTER
(ORANGE) KIT
3
PA
3
LAMICTAL XR
3
PA
gabapentin
1
LAMICTAL XR
STARTER (BLUE)
3
PA
GABITRIL ORAL
TABLET 12 MG, 16
MG
2
LAMICTAL XR
STARTER
(GREEN)
3
PA
GABITRIL ORAL
TABLET 2 MG, 4
MG
3
LAMICTAL XR
STARTER
(ORANGE)
3
PA
GRALISE
3
ST
3
ST
lamotrigine oral
tablet
1
GRALISE 30-DAY
STARTER PACK
3
PA
lamotrigine oral
tablet disintegrating,
dose pk
1
KEPPRA
INTRAVENOUS
KEPPRA ORAL
3
1
KEPPRA XR
3
KLONOPIN
3
lamotrigine oral
tablet extended
release 24hr
LAMICTAL
3
1
LAMICTAL ODT
3
lamotrigine oral
tablet, chewable
dispersible
LAMICTAL ODT
STARTER (BLUE)
3
lamotrigine oral
tablet,disintegrating
1
LAMICTAL ODT
STARTER
(GREEN)
3
LEVETIRACETAM
IN NACL (ISO-OS)
3
levetiracetam
intravenous
1
levetiracetam oral
1
PA
PA
PA
17
Drug Name
Tier
LYRICA
3
MYSOLINE
3
NEURONTIN
3
ONFI
3
oxcarbazepine
1
OXTELLAR XR
3
PEGANONE
3
phenobarbital
1
PHENYTEK
3
phenytoin
1
phenytoin sodium
1
phenytoin sodium
extended
1
POTIGA
Restrictions /
Limits
Drug Name
Tier
PA
valproic acid
1
valproic acid (as
sodium salt)
1
VIMPAT
INTRAVENOUS
3
VIMPAT ORAL
3
ZARONTIN
3
ZONEGRAN
3
zonisamide
1
ST
Restrictions /
Limits
PA
Antiparkinsonism Agents
APOKYN
3
AZILECT
2
benztropine injection
1
3
benztropine oral
1
primidone
1
bromocriptine
1
QUDEXY XR
3
carbidopa
1
roweepra
1
carbidopa-levodopa
1
SABRIL
3
1
SPRITAM
3
carbidopa-levodopaentacapone
TEGRETOL
3
COGENTIN
3
TEGRETOL XR
3
COMTAN
3
DUOPA
3
tiagabine
1
TOPAMAX
3
ELDEPRYL
3
topiramate oral
capsule, sprinkle
1
entacapone
1
LODOSYN
3
TOPIRAMATE
ORAL
CAPSULE,SPRINK
LE,ER 24HR
3
MIRAPEX
3
MIRAPEX ER
3
NEUPRO
3
topiramate oral
tablet
1
PARLODEL
3
pramipexole
1
TRILEPTAL
3
TROKENDI XR
3
PA
valproate sodium
1
PA
PA
PA
18
PA; LA; QL
PA
PA
Drug Name
Tier
Restrictions /
Limits
REQUIP ORAL
TABLET 0.25 MG,
0.5 MG, 1 MG, 2
MG
3
REQUIP ORAL
TABLET 3 MG, 4
MG, 5 MG
3
QL
REQUIP XL
3
PA
ropinirole oral tablet
0.25 mg, 0.5 mg, 1
mg, 2 mg
1
3 mg, 4 mg, 5 mg
1
extended release 24
hr
Drug Name
Tier
Restrictions /
Limits
AXERT
3
CAFERGOT
3
D.H.E.45
3
dihydroergotamine
injection
1
dihydroergotamine
nasal
1
ERGOMAR
3
FROVA
3
QL
frovatriptan
1
QL
IMITREX
3
QL
1
IMITREX
STATDOSE KIT
REFILL
3
QL
RYTARY
3
3
QL
selegiline hcl
1
IMITREX
STATDOSE PEN
SINEMET
3
isometh-dichloralacetaminophn
1
SINEMET CR
3
1
STALEVO 100
3
isomethepten-cafacetaminophen
STALEVO 125
3
MAXALT
3
QL
STALEVO 150
3
MAXALT-MLT
3
QL
STALEVO 200
3
migergot
1
STALEVO 50
3
MIGRALAM
3
STALEVO 75
3
MIGRANAL
3
QL
TASMAR
3
naratriptan
1
QL
tolcapone
1
nodolor
1
trihexyphenidyl
1
PRODRIN
3
ZELAPAR
3
RELPAX
3
ST; QL
Migraine & Cluster Headache
Therapy
rizatriptan
1
QL
sumatriptan
1
QL
almotriptan malate
1
QL
1
QL
ALSUMA
3
PA; QL
sumatriptan
succinate
AMERGE
3
QL
SUMAVEL
DOSEPRO
3
PA
QL
QL
QL
19
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
TREXIMET
3
PA; QL
rivastigmine
1
PA
ZECUITY
3
PA; QL
rivastigmine tartrate
1
PA
zolmitriptan
1
QL
tetrabenazine
1
PA; LA
ZOMIG
2
QL
TYSABRI
3
PA; LA
ZOMIG ZMT
3
QL
XENAZINE
3
PA; LA
Miscellaneous Neurological Therapy
AMPYRA
3
PA; LA; QL
ARICEPT ORAL
TABLET 10 MG, 5
MG
3
ARICEPT ORAL
TABLET 23 MG
3
donepezil oral tablet
1
donepezil oral
1
PA
EXELON
3
galantamine
Muscle Relaxants & Antispasmodic
Therapy
AMRIX
3
baclofen
1
carisoprodol
1
carisoprodol-asacodeine
1
carisoprodol-aspirin
1
chlorzoxazone
1
PA
cyclobenzaprine
1
1
PA
DANTRIUM
INTRAVENOUS
3
HORIZANT
3
ST; QL
DANTRIUM ORAL
3
KEVEYIS
3
PA
dantrolene
1
memantine oral
solution
1
PA
FEXMID
3
memantine oral
tablet
1
PA
LORZONE
3
meprobamate
1
MEMANTINE
ORAL
TABLETS,DOSE
PACK
3
MESTINON
3
MESTINON
TIMESPAN
3
NAMENDA
3
PA
metaxall
1
NAMENDA
TITRATION PAK
3
PA
metaxalone
1
1
NAMENDA XR
3
PA
methocarbamol
injection
NAMZARIC
3
PA
methocarbamol oral
1
NUEDEXTA
3
PA; QL
orphenadrine citrate
injection
1
RAZADYNE
3
PA
3
PA
orphenadrine citrate
oral
1
RAZADYNE ER
PA
PA
20
Restrictions /
Limits
PA; QL
PA
PA
PA
PA
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
PARAFON FORTE
DSC
3
butalbital compound
w/codeine
1
pyridostigmine
bromide
1
butalbitalacetaminop-caf-cod
1
regonol
1
PA
1
revonto
1
PA
butalbitalacetaminophen
ROBAXIN
INJECTION
2
PA
butalbitalacetaminophen-caff
1
ROBAXIN ORAL
3
butalbital-aspirincaffeine
1
ROBAXIN-750
3
BUTRANS
2
RYANODEX
3
capacet
1
SKELAXIN
3
3
CAPITAL WITH
CODEINE
2
SOMA
tizanidine
1
codeine sulfate
1
ZANAFLEX ORAL
CAPSULE
3
codeine-butalbitalasa-caff
1
ZANAFLEX ORAL
TABLET
3
co-gesic
1
DEMEROL
3
DEMEROL (PF)
INJECTION
SOLUTION 100
MG/2 ML, 25
MG/0.5 ML, 75
MG/1.5 ML
3
demerol (pf)
injection solution
100 mg/ml
1
3
PA
PA
Narcotic Analgesics
ABSTRAL
3
PA; QL
acetaminophencodeine
1
ACTIQ
3
ALLZITAL
3
ascomp with codeine
1
ASTRAMORPH-PF
3
PA
BELBUCA
3
PA
BUPAP
3
DEMEROL (PF)
INJECTION
SYRINGE
BUPRENEX
3
PA
dihydrocodeacetaminophen-caff
1
buprenorphine hcl
injection
1
PA
dihydrocodeineaspirin-caff
1
buprenorphine hcl
sublingual
1
DILAUDID
3
butalbital compound
1
DILAUDID-HP
(PF)
3
PA; QL
Restrictions /
Limits
QL
PA
21
Drug Name
Tier
Restrictions /
Limits
diskets
1
DOLOPHINE
3
DURAGESIC
3
duramorph (pf)
1
EMBEDA
3
endocet
1
ESGIC
3
EXALGO ER
3
ST; QL
fentanyl citrate
1
PA; QL
fentanyl citrate (pf)
1
PA
fentanyl transdermal
patch 72 hour 100
mcg/hr, 12 mcg/hr,
25 mcg/hr, 50
mcg/hr, 75 mcg/hr
1
FENTANYL
TRANSDERMAL
PATCH 72 HOUR
37.5 MCG/HOUR,
62.5 MCG/HOUR,
87.5 MCG/HOUR
3
FENTORA
3
FIORICET
3
FIORICET WITH
CODEINE
3
FIORINAL
3
FIORINALCODEINE #3
3
HYCET
Drug Name
Tier
Restrictions /
Limits
HYDROMORPHO
NE INJECTION
SYRINGE 0.5
MG/0.5 ML
3
hydromorphone
injection syringe 1
mg/ml, 2 mg/ml, 4
mg/ml
1
hydromorphone oral
liquid
1
hydromorphone oral
tablet
1
hydromorphone oral
tablet extended
release 24 hr
1
hydromorphone
rectal
1
HYSINGLA ER
3
IBUDONE
3
ibuprofen-oxycodone
1
QL
INFUMORPH P/F
3
PA
KADIAN
3
ST
LAZANDA
3
PA; QL
levorphanol tartrate
1
lorcet (hydrocodone)
1
lorcet hd
1
lorcet plus
1
LORTAB
3
3
lortab 10-325
1
hydrocodoneacetaminophen
1
lortab 5-325
1
lortab 7.5-325
1
hydrocodoneibuprofen
1
LORTAB ELIXIR
3
hydromorphone (pf)
1
PA
margesic
1
hydromorphone
injection solution
1
PA
marten-tab
1
meperidine
1
PA
PA; QL
22
QL
Drug Name
Tier
meperidine (pf)
1
methadone injection
1
methadone oral
Restrictions /
Limits
Drug Name
Tier
oxycodone-aspirin
1
OXYCONTIN
2
1
oxymorphone
1
methadose
1
PERCOCET
3
morphine (pf)
1
2
morphine
concentrate
1
PHRENILIN
FORTE
PRIMLEV
3
morphine injection
1
reprexain
1
MORPHINE
INTRAMUSCULA
R
3
ROXICODONE
3
SUBSYS
3
morphine
intravenous
1
SYNALGOS-DC
3
tencon
1
morphine oral
1
3
morphine rectal
1
TREZIX ORAL
CAPSULE 16320.5-30 MG
MS CONTIN
3
1
NORCO
3
trezix oral capsule
16-356.4-30 mg
ONSOLIS
3
3
OPANA
3
TYLENOLCODEINE #3
OPANA ER
2
TYLENOLCODEINE #4
3
OXAYDO
3
VANATOL LQ
3
oxycodone oral
capsule
1
verdrocet
1
oxycodone oral
concentrate
1
vicodin
1
vicodin es
1
oxycodone oral
solution
1
vicodin hp
1
VICOPROFEN
3
oxycodone oral
tablet
1
XARTEMIS XR
3
OXYCODONE
ORAL
TABLET,ORAL
ONLY,EXT.REL.12
HR
3
XODOL 10/300
3
XODOL 5/300
3
XODOL 7.5/300
3
xolox
1
oxycodoneacetaminophen
1
XTAMPZA ER
3
xylon 10
1
PA
PA
PA
PA
PA; QL
PA
PA; QL
Restrictions /
Limits
QL
PA; QL
PA
23
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
zamicet
1
diflunisal
1
zebutal
1
DISALCID
3
ZOHYDRO ER
3
dologesic (wphenyltoloxamine)
1
DUEXIS
3
PA; QL
DYLOJECT
3
PA
EC-NAPROSYN
3
etodolac
1
EVZIO
3
FELDENE
3
fenoprofen
1
PA; QL
Non-Narcotic Analgesics
ANAPROX DS
3
ARTHROTEC 50
3
PA
ARTHROTEC 75
3
PA
aspirin oral tablet
0
ACA; OTC
aspirin oral
tablet,delayed
release (dr/ec)
1
BUNAVAIL
3
QL
FLECTOR
3
buprenorphinenaloxone
1
PA
flurbiprofen
1
butorphanol tartrate
injection
1
PA
ibuprofen
1
INDOCIN ORAL
2
butorphanol tartrate
nasal
1
QL
INDOCIN RECTAL
3
indomethacin
1
CALDOLOR
3
PA
ketoprofen
1
CAMBIA
3
PA; QL
ketorolac
1
QL
CELEBREX
3
QL
klofensaid ii
1
QL
celecoxib
1
QL
levacet
1
choline,magnesium
salicylate
1
meclofenamate
1
CONZIP
3
mefenamic acid
1
DAYPRO
3
meloxicam
1
diclofenac potassium
1
MOBIC
3
diclofenac sodium
oral
1
nabumetone
1
nalbuphine
1
diclofenac sodium
topical drops
1
naloxone injection
solution
1
diclofenac sodium
topical gel
1
naloxone injection
syringe
1
diclofenacmisoprostol
1
naltrexone
1
NAPRELAN CR
3
ST
QL
24
QL
PA
PA
Drug Name
Tier
Restrictions /
Limits
NAPROSYN
3
naproxen
1
naproxen sodium
1
NARCAN
3
novagesic
1
NUCYNTA
3
NUCYNTA ER
3
oxaprozin
1
PENNSAID
3
pentazocinenaloxone
1
piroxicam
1
PONSTEL
3
RELAGESIC
3
REVIA
3
rhinoflex
1
RYBIX ODT
3
salsalate
1
SPRIX
3
ST; QL
SUBOXONE
2
QL
sulindac
1
SYNAPRYN
3
TALWIN
3
TIVORBEX
3
tolmetin
1
TRAMADOL
ORAL
CAPSULE,ER
BIPHASE 24 HR
25-75
3
tramadol oral tablet
tramadol oral tablet
extended release 24
hr
QL
Drug Name
Tier
Restrictions /
Limits
tramadol oral tablet,
er multiphase 24 hr
1
tramadolacetaminophen
1
ULTRACET
3
ULTRAM
3
ULTRAM ER
3
VIMOVO
3
PA
VIVITROL
3
LA; QL
VOLTAREN
3
VOLTAREN-XR
3
zflex
1
ZIPSOR
3
PA
ZORVOLEX
2
PA
ZUBSOLV
3
Psychotherapeutic Drugs
ABILIFY
3
QL
ABILIFY
MAINTENA
3
QL
ADASUVE
3
ADDERALL
3
ADDERALL XR
3
PA
ADZENYS XRODT
3
PA
alprazolam
1
alprazolam intensol
1
AMBIEN
3
AMBIEN CR
3
amitriptyline
1
amitriptylinechlordiazepoxide
1
1
1
amoxapine
1
ANAFRANIL
3
PA
PA
25
Drug Name
Tier
Restrictions /
Limits
Drug Name
APLENZIN
3
APTENSIO XR
3
aripiprazole oral
solution
1
aripiprazole oral
tablet
PA
CLOZAPINE
ORAL
TABLET,DISINTE
GRATING 150 MG,
200 MG
3
1
QL
CLOZARIL
3
CONCERTA
3
aripiprazole oral
1
QL
CYMBALTA
3
ARISTADA
3
QL
DAYTRANA
3
armodafinil
1
PA; QL
desipramine
1
ATIVAN
3
DESOXYN
3
BELSOMRA
3
DESVENLAFAXIN
E
3
ST
BRISDELLE
3
ST
1
DESVENLAFAXIN
E FUMARATE
3
bupropion hcl
buspirone
1
dexedrine
1
BUTISOL
3
3
CELEXA
3
DEXEDRINE
SPANSULE
chlordiazepoxide hcl
1
dexmethylphenidate
1
chlorpromazine
injection
1
dextroamphetamine
1
1
chlorpromazine oral
1
dextroamphetamineamphetamine
citalopram
1
diazepam injection
1
clomipramine
1
diazepam intensol
1
clonidine hcl
1
diazepam oral
1
clorazepate
dipotassium
1
DORAL
3
doxepin
1
clozapine oral tablet
1
duloxetine
1
clozapine oral
100 mg, 12.5 mg, 25
mg
1
DYANAVEL XR
3
EDLUAR
3
EFFEXOR XR
3
EMSAM
3
ergoloid
1
escitalopram oxalate
1
PA; QL
PA
26
Tier
Restrictions /
Limits
PA
PA
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
HALCION
3
HALDOL
3
HALDOL
DECANOATE
3
haloperidol
1
haloperidol
decanoate
1
haloperidol lactate
injection
1
haloperidol lactate
oral
1
HETLIOZ
3
imipramine hcl
1
imipramine pamoate
1
INTERMEZZO
3
INTUNIV ER
3
INVEGA
3
ST; QL
INVEGA
SUSTENNA
3
QL
INVEGA TRINZA
3
IRENKA
3
KAPVAY
3
estazolam
1
eszopiclone
1
EVEKEO
3
FANAPT
3
FAZACLO
3
FETZIMA
3
ST
flumazenil
1
PA
fluoxetine oral
capsule
1
fluoxetine oral
capsule,delayed
release(dr/ec)
1
fluoxetine oral
solution
1
fluoxetine oral tablet
10 mg, 20 mg
1
FLUOXETINE
ORAL TABLET 60
MG
3
fluphenazine
decanoate
1
fluphenazine hcl
injection
1
fluphenazine hcl oral
1
KHEDEZLA
3
ST
flurazepam
1
LATUDA
3
ST; QL
fluvoxamine
1
LEXAPRO
3
FOCALIN
3
lithium carbonate
1
FOCALIN XR
3
lithium citrate
1
FORFIVO XL
3
PA
LITHOBID
3
GEODON
INTRAMUSCULA
R
3
PA
lorazepam
1
lorazepam intensol
1
GEODON ORAL
3
loxapine succinate
1
guanfacine
1
LUNESTA
3
guanidine
1
maprotiline
1
QL
ST; QL
QL
ST
PA
QL
PA
PA
PA; LA
PA
QL
27
Drug Name
Tier
Restrictions /
Limits
MARPLAN
3
METADATE CD
3
metadate er
1
methamphetamine
1
METHYLIN
3
methylphenidate
1
mirtazapine
1
modafinil
1
molindone
1
NARDIL
3
nefazodone
1
NORPRAMIN
3
nortriptyline
1
NUPLAZID
3
PA; LA
NUVIGIL
3
PA; QL
olanzapine
intramuscular
1
PA; QL
olanzapine oral
1
olanzapinefluoxetine
1
OLEPTRO ER
3
ORAP
Drug Name
Tier
Restrictions /
Limits
perphenazineamitriptyline
1
PEXEVA
3
phenelzine
1
pimozide
1
PRISTIQ
2
procentra
1
protriptyline
1
PROVIGIL
3
PROZAC
3
PROZAC WEEKLY
3
quazepam
1
quetiapine oral
tablet 100 mg, 200
mg, 25 mg, 300 mg
1
quetiapine oral
tablet 400 mg, 50 mg
1
QUILLICHEW ER
3
QUILLIVANT XR
3
REMERON
3
REMERON
SOLTAB
3
3
RESTORIL
3
oxazepam
1
REXULTI
3
paliperidone
1
RISPERDAL
3
PAMELOR
3
3
QL
PARNATE
3
RISPERDAL
CONSTA
paroxetine hcl
1
RISPERDAL MTAB
3
QL
PAXIL CR
3
2
risperidone oral
solution
1
PAXIL ORAL
SUSPENSION
3
risperidone oral
tablet
1
PAXIL ORAL
TABLET
1
risperidone oral
1
perphenazine
PA; QL
QL
PA
QL
28
ST
ST; QL
PA; QL
ST; QL
QL
PA
QL
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
RITALIN
3
venlafaxine
1
RITALIN LA
3
VERSACLOZ
3
ROZEREM
3
QL
2
ST
SAPHRIS (BLACK
CHERRY)
3
ST; QL
VIIBRYD ORAL
TABLET
3
ST
SARAFEM
3
seconal sodium
1
VIIBRYD ORAL
TABLETS,DOSE
PACK 10 MG (7)20 MG (23)
SEROQUEL ORAL
TABLET 100 MG,
200 MG, 25 MG,
300 MG
3
2
ST
SEROQUEL ORAL
TABLET 400 MG,
50 MG
3
VIIBRYD ORAL
TABLETS,DOSE
PACK 10 MG (7)20 MG (7)-40 MG
(16)
VRAYLAR
3
PA; QL
VYVANSE
3
SEROQUEL XR
2
WELLBUTRIN SR
3
sertraline
1
WELLBUTRIN XL
3
SILENOR
3
XANAX
3
SONATA
3
XANAX XR
3
STRATTERA
3
XYREM
3
SURMONTIL
3
zaleplon
1
SYMBYAX
3
1
temazepam
1
zenzedi oral tablet
10 mg, 5 mg
thioridazine
1
3
thiothixene
1
TOFRANIL
3
ZENZEDI ORAL
TABLET 15 MG,
2.5 MG, 20 MG, 30
MG, 7.5 MG
TRANXENE TTAB
3
ziprasidone hcl
1
ZOLOFT
3
tranylcypromine
1
zolpidem
1
trazodone
1
ZOLPIMIST
3
PA
triazolam
1
PA; QL
1
trimipramine
1
ZYPREXA
INTRAMUSCULA
R
3
trifluoperazine
TRINTELLIX
3
ZYPREXA ORAL
3
QL
VALIUM
3
ST
QL
QL
PA
ST
PA; LA
QL
29
Drug Name
Tier
ZYPREXA
RELPREVV
3
ZYPREXA ZYDIS
3
Restrictions /
Limits
Drug Name
Tier
SOTALOL
INTRAVENOUS
3
sotalol oral
1
Cardiovascular, Hypertension &
Lipids
SOTYLIZE
3
TIKOSYN
3
Antiarrhythmic Agents
Antihypertensive Therapy
amiodarone
1
ACCUPRIL
3
BETAPACE
3
ACCURETIC
3
BETAPACE AF
3
acebutolol
1
CORDARONE
3
ACEON
3
disopyramide
phosphate
1
ADALAT CC
3
afeditab cr
1
flecainide
1
ALDACTAZIDE
3
mexiletine
1
ALDACTONE
3
MULTAQ
3
ALTACE
3
NORPACE
3
amiloride
1
NORPACE CR
ORAL CAPSULE,
EXTENDED
RELEASE 100 MG
2
amiloridehydrochlorothiazide
1
amlodipine
1
NORPACE CR
ORAL CAPSULE,
EXTENDED
RELEASE 150 MG
3
amlodipinebenazepril
1
amlodipinevalsartan
1
pacerone
1
1
amlodipinevalsartan-hcthiazid
1
procainamide
propafenone
1
ATACAND
3
quinidine gluconate
injection
1
ATACAND HCT
3
atenolol
1
quinidine gluconate
oral
1
atenololchlorthalidone
1
quinidine sulfate
1
AVALIDE
3
RYTHMOL
3
AVAPRO
3
RYTHMOL SR
3
AZOR
2
sotalol af
1
QL
PA
PA
30
Restrictions /
Limits
PA
ST
Drug Name
Tier
Restrictions /
Limits
benazepril
1
benazeprilhydrochlorothiazide
1
BENICAR
2
ST
BENICAR HCT
2
ST
betaxolol
1
BIDIL
3
bisoprolol fumarate
1
bisoprololhydrochlorothiazide
1
BREVIBLOC
3
BREVIBLOC IN
NACL (ISO-OSM)
3
bumetanide injection
1
bumetanide oral
Drug Name
Tier
CARDIZEM LA
ORAL TABLET
EXTENDED
RELEASE 24 HR
120 MG
2
CARDIZEM LA
ORAL TABLET
EXTENDED
RELEASE 24 HR
180 MG, 240 MG,
300 MG, 360 MG,
420 MG
3
CARDURA
3
CARDURA XL
3
carvedilol
1
CATAPRES
3
1
CATAPRES-TTS-1
3
BYSTOLIC
2
CATAPRES-TTS-2
3
CALAN
3
CATAPRES-TTS-3
3
CALAN SR
3
chlorothiazide
1
candesartan
1
chlorothiazide
sodium
1
candesartanhydrochlorothiazid
1
chlorthalidone
1
captopril
1
3
captoprilhydrochlorothiazide
1
CLEVIPREX
INTRAVENOUS
EMULSION 25
MG/50 ML
CARDENE IV
3
3
CARDENE IV IN
DEXTROSE
3
CARDENE IV IN
SODIUM
CHLORIDE
3
CLEVIPREX
INTRAVENOUS
EMULSION 50
MG/100 ML
clonidine
1
clonidine hcl
1
CARDENE SR
3
1
CARDIZEM
3
CARDIZEM CD
3
clorpres oral tablet
0.1-15 mg, 0.2-15
mg
PA
PA
Restrictions /
Limits
ST
PA
PA
31
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
eprosartan
1
esmolol
1
ethacrynate sodium
1
EXFORGE
3
EXFORGE HCT
3
felodipine
1
FLOLAN
3
fosinopril
1
fosinoprilhydrochlorothiazide
1
furosemide injection
1
furosemide oral
1
guanfacine
1
HEMANGEOL
3
hydralazine injection
1
hydralazine oral
1
hydrochlorothiazide
1
HYZAAR
3
indapamide
1
INDERAL LA
3
INDERAL XL
3
INNOPRAN XL
2
INSPRA
3
irbesartan
1
irbesartanhydrochlorothiazide
1
isradipine
1
CLORPRES ORAL
TABLET 0.3-15
MG
3
COREG
3
COREG CR
3
CORGARD
3
corlopam
1
CORZIDE
3
COZAAR
3
DEMADEX
3
DEMSER
3
DIBENZYLINE
3
DILACOR XR
3
diltiazem
1
DIOVAN
3
DIOVAN HCT
3
DIURIL
3
DIURIL IV
3
doxazosin
1
DUTOPROL
2
DYAZIDE
3
DYRENIUM
3
EDARBI
3
ST
EDARBYCLOR
3
ST
EDECRIN
3
enalapril maleate
1
enalaprilat
1
enalaprilhydrochlorothiazide
1
labetalol
intravenous
1
EPANED
3
labetalol oral
1
eplerenone
1
LASIX
3
epoprostenol
(glycine)
1
LEVATOL
3
lisinopril
1
PA
PA
PA; LA
32
Restrictions /
Limits
PA
PA; LA
PA
PA
PA
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
lisinoprilhydrochlorothiazide
1
moexipril
1
3
moexiprilhydrochlorothiazide
1
LOPRESSOR HCT
LOPRESSOR
INTRAVENOUS
3
nadolol
1
3
nadololbendroflumethiazide
1
LOPRESSOR
ORAL
1
losartan
1
nicardipine
intravenous
losartanhydrochlorothiazide
1
nicardipine oral
1
nifedical xl
1
LOTENSIN
3
nifedipine
1
LOTENSIN HCT
3
nimodipine
1
LOTREL
3
nisoldipine
1
MAVIK
3
NORVASC
3
MAXZIDE
3
NYMALIZE
3
PA
MAXZIDE-25MG
3
ORENITRAM
3
PA; LA
methyclothiazide
1
papaverine injection
1
PA
methyldopa
1
papaverine oral
1
methyldopahydrochlorothiazide
1
perindopril
erbumine
1
methyldopate
1
phenoxybenzamine
1
metolazone
1
1
phentolamine
injection recon soln
1
metoprolol succinate
metoprolol tahydrochlorothiaz
1
3
metoprolol tartrate
intravenous
1
PHENTOLAMINE
INJECTION
SOLUTION
pindolol
1
metoprolol tartrate
oral
1
prazosin
1
PRESTALIA
3
MICARDIS
3
PRINIVIL
3
MICARDIS HCT
3
PROCARDIA
3
MICROZIDE
3
PROCARDIA XL
3
MINIPRESS
3
1
propranolol
intravenous
1
minoxidil
PA
PA
PA
PA
PA
PA
33
Drug Name
Tier
propranolol oral
1
propranololhydrochlorothiazid
1
quinapril
1
quinaprilhydrochlorothiazide
1
ramipril
1
REMODULIN
3
reserpine
1
SECTRAL
3
SODIUM
EDECRIN
3
spironolactone
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
torsemide
20 mg/2 ml (10
mg/ml)
1
TORSEMIDE
INTRAVENOUS
SOLUTION 50
MG/5 ML (10
MG/ML)
3
torsemide oral
1
trandolapril
1
trandolaprilverapamil
1
triamterenehydrochlorothiazid
1
1
spironolactonhydrochlorothiaz
1
TRIBENZOR
2
TWYNSTA
3
SULAR
3
UPTRAVI
3
TARKA
3
valsartan
1
TEKTURNA
3
ST
3
ST
valsartanhydrochlorothiazide
1
TEKTURNA HCT
telmisartan
1
VASERETIC
3
telmisartanamlodipine
1
VASOTEC
3
veletri
1
PA; LA
telmisartanhydrochlorothiazid
1
verapamil
intravenous
1
PA
TENEX
3
verapamil oral
1
TENORETIC 100
3
VERELAN
3
TENORETIC 50
3
VERELAN PM
3
TENORMIN
3
ZEBETA
3
terazosin
1
ZESTORETIC
3
TEVETEN
3
ZESTRIL
3
TIAZAC
3
ZIAC
3
timolol maleate
1
TOPROL XL
3
PA; LA
PA
PA
34
Cardiac Glycosides
digitek
1
PA
ST
PA; LA
Drug Name
Tier
digox
1
digoxin injection
1
digoxin oral
1
LANOXIN
INJECTION
3
LANOXIN ORAL
3
LANOXIN
PEDIATRIC
3
Restrictions /
Limits
PA
PA
PA
Coagulation Therapy
Drug Name
Tier
Restrictions /
Limits
COUMADIN
INTRAVENOUS
2
PA
COUMADIN ORAL
3
CYKLOKAPRON
3
dipyridamole
1
DURLAZA
3
EFFIENT
2
ELIQUIS
2
QL
ELOCTATE
3
PA; LA
PA
PA
ADVATE
3
PA; LA
enoxaparin
1
AFSTYLA
3
PA; LA
FEIBA NF
3
AGGRENOX
3
fondaparinux
1
ALPHANATE
3
PA; LA
FRAGMIN
3
ALPHANINE SD
3
PA; LA
HELIXATE FS
3
PA; LA
AMICAR
3
HEMOFIL M HIGH
3
PA; LA
aminocaproic acid
1
PA
HEMOFIL M LOW
3
PA; LA
ARGATROBAN
3
PA
HEMOFIL M MID
3
PA; LA
ARGATROBAN IN
0.9 % SOD CHLOR
3
PA
HEMOFIL M
SUPER HIGH
3
PA; LA
ARGATROBAN IN
NACL (ISO-OS)
3
hep flush-10 (pf)
1
ARIXTRA
3
heparin (porcine)
1
aspirin-dipyridamole
1
1
BEBULIN
3
PA; LA
BENEFIX
3
PA; LA
heparin (porcine) in
5 % dex intravenous
parenteral solution
12,500 unit/250 ml
BRILINTA
2
1
PA
CEPROTIN (BLUE
BAR)
3
PA; LA
CEPROTIN
(GREEN BAR)
3
PA; LA
cilostazol
1
clopidogrel
1
5 % dex intravenous
parenteral solution
20,000 unit/500 ml
(40 unit/ml), 25,000
unit/250 ml(100
unit/ml), 25,000
unit/500 ml (50
unit/ml)
CORIFACT
3
nacl (pf)
1
PA
PA; LA
PA; LA
35
Drug Name
Tier
heparin flush
1
heparin
flush(porcine)0.9nacl
1
heparin lock flush
1
heparin lock flush
(porcine)
1
heparin
lockflush(porcine)(pf
)
1
HEPARIN(PORCIN
E) IN 0.45% NACL
INTRAVENOUS
PARENTERAL
SOLUTION 12,500
UNIT/250 ML
3
heparin(porcine) in
0.45% nacl
intravenous
parenteral solution
25,000 unit/250 ml,
25,000 unit/500 ml
1
heparin, porcine (pf)
1
HUMATE-P
3
jantoven
1
KCENTRA
3
KOATE-DVI
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
monoject prefill
advanced (pf)
1
MONONINE
3
PA; LA
NOVOSEVEN RT
3
PA; LA
NPLATE
3
PA; LA
pentoxifylline
1
PERSANTINE
3
PHYTONADIONE
(VITAMIN K1)
3
PLAVIX
3
PRADAXA
3
QL
PROFILNINE
3
PA; LA
PROMACTA
3
PA; LA
protamine
1
PA
RECOMBINATE
3
PA; LA
RIASTAP
3
PA; LA
RIXUBIS
3
PA; LA
SAVAYSA
3
ticlopidine
1
tranexamic acid
1
PA
TRETTEN
3
PA; LA
PA
vitamin k
1
PA
3
PA; LA
vitamin k1
1
PA
KOGENATE FS
3
PA; LA
VONVENDI
3
PA; LA
KOVALTRY
3
PA; LA
warfarin
1
LOVENOX
SUBCUTANEOUS
SOLUTION
3
PA
WILATE
3
2
LOVENOX
SUBCUTANEOUS
SYRINGE
3
XARELTO ORAL
TABLET
3
MEPHYTON
2
XARELTO ORAL
TABLETS,DOSE
PACK
MONOCLATE-P
3
XYNTHA
3
PA; LA
monoject prefill (pf)
1
XYNTHA
SOLOFUSE
3
PA; LA
PA
PA; LA
PA; LA
36
PA
PA; LA
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
ZONTIVITY
3
PA
KYNAMRO
3
Lipid/Cholesterol Lowering Agents
LESCOL
3
ALTOPREV
3
LESCOL XL
3
amlodipineatorvastatin
1
LIPITOR
3
LIPOFEN
3
ANTARA
3
LIVALO
3
ST; QL
atorvastatin
1
LOFIBRA
3
ST
CADUET
3
LOPID
3
cholestyramine (with
sugar)
1
lovastatin
1
cholestyramine light
1
niacin
1
COLESTID
FLAVORED
3
NIACOR
3
3
COLESTID ORAL
GRANULES
2
NIASPAN
EXTENDEDRELEASE
COLESTID ORAL
TABLET
3
omega-3 acid ethyl
esters
1
PA
colestipol
1
PRALUENT PEN
2
PA; LA; QL
CRESTOR
3
PRALUENT
SYRINGE
2
PA; LA; QL
fenofibrate
micronized
1
PRAVACHOL
3
fenofibrate
nanocrystallized
1
pravastatin
1
prevalite
1
FENOFIBRATE
ORAL CAPSULE
3
QUESTRAN
3
3
fenofibrate oral
tablet
1
QUESTRAN
LIGHT
2
PA; LA; QL
fenofibric acid
1
REPATHA
SURECLICK
fenofibric acid
(choline)
1
REPATHA
SYRINGE
2
PA; LA; QL
FENOGLIDE
3
ST
rosuvastatin
1
FIBRICOR
3
ST
simvastatin
1
fluvastatin
1
TRICOR
3
gemfibrozil
1
TRIGLIDE
3
JUXTAPID
3
TRILIPIX
3
ST
PA; QL
Restrictions /
Limits
PA; LA
ST
37
Drug Name
Tier
Restrictions /
Limits
Drug Name
VASCEPA
3
PA
2
VYTORIN 10-10
3
ST
VYTORIN 10-20
3
ST
VYTORIN 10-40
3
ST
NITRO-DUR
TRANSDERMAL
PATCH 24 HOUR
0.3 MG/HR, 0.8
MG/HR
VYTORIN 10-80
3
ST
1
WELCHOL
2
ZETIA
2
ZOCOR
3
nitroglycerin in 5 %
dextrose intravenous
solution 100 mg/250
ml (400 mcg/ml),
200 mg/500 ml (400
mcg/ml), 50 mg/250
ml (200 mcg/ml)
nitroglycerin in 5 %
dextrose intravenous
solution 25 mg/250
ml (100 mcg/ml), 50
mg/500 ml (100
mcg/ml)
1
nitroglycerin
intravenous
1
nitroglycerin oral
1
nitroglycerin
transdermal
1
QL
Miscellaneous Cardiovascular
Agents
CORLANOR
3
PA; QL
ENTRESTO
3
PA
NATRECOR
3
PA
RANEXA
2
VECAMYL
3
Nitrates
Tier
Restrictions /
Limits
PA
PA
DILATRATE-SR
2
ISOCHRON
3
ISORDIL
3
nitroglycerin
translingual
1
ISORDIL
TITRADOSE
3
NITROLINGUAL
3
isosorbide dinitrate
1
NITROMIST
3
isosorbide
mononitrate
1
NITRONAL
3
NITROSTAT
3
MINITRAN
3
nitro-time
1
nitro-bid
1
Dermatologicals/Topical Therapy
NITRO-DUR
TRANSDERMAL
PATCH 24 HOUR
0.1 MG/HR, 0.2
MG/HR, 0.4
MG/HR, 0.6
MG/HR
3
Antipsoriatic / Antiseborrheic
38
PA
acitretin
1
calcipotriene
1
QL
calcipotrienebetamethasone
1
QL
calcitrene
1
QL
calcitriol
1
QL
Drug Name
Tier
COAL TAR
3
COSENTYX
3
COSENTYX (2
SYRINGES)
3
COSENTYX PEN
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
SORIATANE
3
PA; LA
SORILUX
3
ST; QL
PA
STELARA
3
PA; LA; QL
1
3
PA; LA
sulfacetamide
sodium
COSENTYX PEN
(2 PENS)
3
PA
sulfacetamide
sodium-urea
1
DOVONEX
3
ST; QL
TACLONEX
3
QL
drithocreme hp
1
3
PA; LA
ENSTILAR
3
TALTZ
AUTOINJECTOR
EPIFOAM
3
3
PA; LA
hydrocortisonepramoxine
1
TALTZ
AUTOINJECTOR
(2 PACK)
PA; LA
3
OVACE PLUS
SHAMPOO
3
TALTZ
AUTOINJECTOR
(3 PACK)
3
OVACE
TALTZ SYRINGE
3
PA; LA
OVACE PLUS
TOPICAL
CLEANSER,EXTE
NDED RELEASE
3
TALTZ SYRINGE
(2 PACK)
3
PA; LA
TALTZ SYRINGE
(3 PACK)
3
PA; LA
OVACE PLUS
TOPICAL CREAM
3
TERSI FOAM
3
OVACE PLUS
TOPICAL FOAM
3
VECTICAL
3
ZITHRANOL
3
OVACE PLUS
TOPICAL LOTION
3
ZITHRANOL-RR
3
OVACE PLUS
WASH
3
PRAMOSONE
PA; QL
PA
QL
Burn Therapy
SILVADENE
3
3
silver sulfadiazine
1
PRAMOSONE E
3
ssd
1
PROMISEB
COMPLETE
3
thermazene
1
seb-prev
1
BENSAL HP
3
selenium sulfide
1
INOVA 4-1
3
SELRX
3
INOVA 8-2
3
Keratolytics
39
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
KERALYT RX
3
CARAC
3
KERALYT SCALP
COMPLETE
3
cem-urea
1
CONDYLOX
2
latrix xm
1
CORTANE-B
3
PODOCON
3
3
POTASSIUM
HYDROXIDE
3
DERMASORB XM
COMPLETE KIT
diclofenac sodium
1
salacyn
1
doxepin
1
SALEX
3
EFUDEX
3
salicylic acid
1
eletone
1
salicylic acid erceramides
1
ELIDEL
3
SALKERA
3
emulsion sb
1
salvax
1
EPICERAM
3
SALVAX DUO
PLUS
3
FLUOROPLEX
3
3
SULFUR
2
FLUOROURACIL
TOPICAL CREAM
0.5 %
ULTRASAL-ER
3
1
VIRASAL
3
fluorouracil topical
cream 5 %
fluorouracil topical
solution
1
GORDONS UREA
3
hpr
1
Miscellaneous Dermatologicals
8-MOP
2
ALEVICYN
ANTIPRURITIC
3
ALUVEA
3
hpr plus
1
ATOPICLAIR
3
hpr plus hydrogel
1
ATRAPRO CP
3
3
ATRAPRO
HYDROGEL
3
HPR PLUS-MB
HYDROGEL
HYDRO 35
3
AURSTAT
3
HYDRO 40
3
avo cream
1
KERAFOAM
3
BIAFINE
EMULSION
3
KERALAC
3
lactic acid
1
bp-50% urea
1
lactic acid e
1
captracin
1
latrix
1
40
Restrictions /
Limits
PA
QL
Drug Name
Tier
Restrictions /
Limits
LEVULAN
3
RENOVO
3
LOUTREX
3
RYNODERM
3
luxamend
1
SILMANIX
3
mac
1
silver nitrate
1
mb hydrogel
1
1
mb hydrogel
(cyclomethicone)
1
silver nitrate
applicators
1
methoxsalen rapid
1
methyl salicylate
1
sinelee topical
adhesive
patch,medicated
0.0375-5 %
NEOSALUS
3
3
NEUVAXIN
3
OXSORALEN
3
OXSORALEN
ULTRA
3
SINELEE
TOPICAL
ADHESIVE
PATCH,MEDICAT
ED 0.05-5 %
SOLAICE
3
pain relief
(capsaicin)
1
SOLARAZE
3
sonafine
1
PANRETIN
3
tacrolimus
1
PICATO
3
TOLAK
3
podofilox
1
3
TROPAZONE
CREAM
3
PRESERA
PROMISEB
3
3
PROTOPIC
3
TROPAZONE
LOTION
pruclair
1
U-CORT
3
prudoxin
1
umecta
1
prumyx
1
UMECTA PD
3
prutect
1
URAMAXIN
3
QROXIN
3
URAMAXIN GT
3
QUTENZA
3
urea
1
rea lo 39
1
urea nail stick
1
rea lo 40
1
urea-hyaluronate
sodium
1
REGRANEX
3
ure-k
1
RELYYT
3
UTOPIC
3
remeven
1
QL
QL
PA
PA
PA
Drug Name
Tier
Restrictions /
Limits
PA
QL
41
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
UVADEX
3
PA
BENZACLIN
3
VALCHLOR
3
PA; LA; QL
3
VEHICLE/N
3
BENZACLIN
PUMP
VEHICLE/N MILD
3
BENZAMYCIN
3
VEREGEN
3
BENZAMYCINPA
K
2
XCLAIR
3
BENZEFOAM
3
ZANABIN
2
3
BENZEFOAM
ULTRA
3
ZONALON
benzepro
1
BENZEPRO
(MICROSPHERES)
3
benzoyl peroxide
1
bp 10-1
1
bpo
1
claravis
1
cleansing wash
1
CLEOCIN T
3
CLINDACIN ETZ
3
clindacin p
1
CLINDACIN PAC
3
CLINDAGEL
3
clindamycin
phosphate
1
clindamycin-benzoyl
peroxide
1
DERMAPAK PLUS
3
DIFFERIN
3
DUAC
3
EPIDUO
2
EPIDUO FORTE
3
ery pads
1
erygel
1
PA
Therapy For Acne
ABSORICA
3
ACANYA
3
ACZONE
3
adapalene
1
AKNE-MYCIN
3
APOP
3
ATRALIN
3
AVAR LS
TOPICAL
CLEANSER
3
AVAR LS
TOPICAL FOAM
3
AVAR LS
TOPICAL PADS,
MEDICATED
3
avar topical cleanser
1
AVAR TOPICAL
FOAM
3
AVAR TOPICAL
PADS,
MEDICATED
3
AVAR-E GREEN
3
AVAR-E LS
3
avita
1
AZELEX
2
PA
PA
PA
42
Restrictions /
Limits
PA
PA
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
erythromycin with
ethanol
1
rosula cleansing
cloths
1
erythromycinbenzoyl peroxide
1
SOOLANTRA
3
ss 10-2
1
EVOCLIN
3
SSS 10-4
3
FABIOR
3
sss 10-5
1
FINACEA
3
3
sulfacetamide
sodium-sulfur
1
FINACEA PLUS
INOVA
3
1
METROCREAM
3
sulfacetamide sodsulfur-urea
METROGEL
3
sulfacetamidesulfur-cleansr23
1
METROLOTION
3
sulfacleanse 8-4
1
metronidazole
1
1
MIRVASO
3
sulfact na-sulavobnz-otn-ocsa
myorisan
1
SUMADAN
3
neuac
1
SUMADAN XLT
3
NORITATE
2
SUMAXIN
3
NUOX
3
SUMAXIN CP
3
ONEXTON
3
SUMAXIN TS
3
PACNEX
3
TAZORAC
3
PLEXION
3
tretinoin
1
PLEXION
CLEANSING
CLOTHS
3
tretinoin
microspheres
1
TRETIN-X
3
PR BENZOYL
PEROXIDE
3
TRETIN-X (GEL)
3
PA
RETIN-A
3
TRETIN-X CREAM
KIT
3
PA
RETIN-A MICRO
3
VANOXIDE-HC
3
RETIN-A MICRO
PUMP
3
VELTIN
3
rosadan
1
zenatane
1
ROSANIL
3
zencia
1
ROSULA
3
ZIANA
3
PA
PA
PA
Topical Anesthetics
43
Drug Name
Tier
Restrictions /
Limits
BUCALSEP
3
XYLOCAINE-MPF
3
ethyl chloride
1
ZINGO
3
glydo
1
Topical Antibacterials
lidocaine
1
ALTABAX
3
lidocaine (pf)
1
CENTANY
3
lidocaine hcl
1
CENTANY AT
3
lidocaine hclhydrocortison ac
1
CORTISPORIN
2
gentamicin
1
lidocaine viscous
1
KLARON
3
lidocaineepinephrine
1
mupirocin
1
lidocaine-prilocaine
1
mupirocin calcium
1
LIDOCAINETETRACAINE
3
NEO-SYNALAR
3
3
LIDODERM
3
NEO-SYNALAR
KIT
lido-k
1
sulfacetamide
sodium (acne)
1
lidopin topical
cream 3 %
1
SULFAMYLON
3
LIDOPIN TOPICAL
CREAM 3.25 %
3
LIDORX
PA
Drug Name
Tier
Restrictions /
Limits
PA
Topical Antifungals
BENSAL HP
3
3
ciclodan
1
LIDOVEX
3
ciclopirox
1
LIVIXIL PAK
3
PA
1
LP LITE PAK
3
PA
ciclopirox-urecamph-menth-euc
lta pre-attached
1
1
NOVACORT
(WITH ALOE)
3
ciclopirox-vite-nail
lacq remo
clotrimazole
1
PLIAGLIS
3
1
relador pak
1
clotrimazolebetamethasone
relador pak plus
1
CNL 8 NAIL
3
SYNERA
3
econazole
1
XYLOCAINE
3
ECOZA
3
XYLOCAINEEPINEPHRINE
3
ERTACZO
3
EXELDERM
3
PA
PA
44
PA
PA
PA; QL
Drug Name
Tier
EXODERM
Restrictions /
Limits
Drug Name
Tier
3
DENAVIR
3
EXTINA
3
LIDOVIR
3
JUBLIA
3
PA
XERESE
3
KERYDIN
3
PA
ZOVIRAX
3
ketoconazole
1
Topical Corticosteroids
ketodan kit
1
ala-cort
1
LOPROX
3
ALA-SCALP
3
LOTRISONE
3
alclometasone
1
LUZU
3
amcinonide
1
MENTAX
3
apexicon e
1
NAFTIFINE
TOPICAL CREAM
1%
3
AQUA GLYCOLIC
HC
3
1
betamethasone
dipropionate
1
naftifine topical
cream 2 %
3
betamethasone
valerate
1
NAFTIN
NIZORAL
3
1
nyamyc
1
betamethasone,
augmented
NYATA
3
CAPEX
3
nystatin
1
clobetasol scalp
1
PA
nystatintriamcinolone
1
clobetasol topical
cream
1
PA
nystop
1
1
PA; QL
oxiconazole
1
clobetasol topical
foam
OXISTAT
3
clobetasol topical
gel
1
PA
PEDIADERM AF
3
1
PA
PENLAC
3
clobetasol topical
lotion
TRIACETIN
3
1
PA
TRIPLE DYE
3
clobetasol topical
ointment
VUSION
3
clobetasol topical
shampoo
1
PA
XOLEGEL
3
clobetasol topical
spray,non-aerosol
1
PA
PA; QL
PA; QL
Topical Antivirals
acyclovir
Restrictions /
Limits
1
45
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
FIRSTHYDROCORTISO
NE
3
fluocinolone
1
fluocinolone and
shower cap
1
fluocinonide
1
fluocinonide-e
1
Restrictions /
Limits
clobetasol-emollient
topical cream
1
PA
clobetasol-emollient
topical foam
1
PA; QL
CLOBEX
3
CLOCORTOLONE
PIVALATE
3
clodan
1
CLODERM
3
flurandrenolide
1
CORDRAN
3
fluticasone
1
CORDRAN TAPE
SMALL ROLL
3
halobetasol
propionate
1
cormax
1
HALOG
3
CUTIVATE
3
hydrocortisone
1
DERMASMOOTHE/FS
BODY OIL
3
hydrocortisone
butyrate
1
3
hydrocortisone
butyr-emollient
1
DERMASMOOTHE/FS
SCALP OIL
hydrocortisone
valerate
1
DERMASORB HC
COMPLETE KIT
3
hydrocortisone-min
oil-wht pet
1
DERMASORB TA
COMPLETE KIT
3
KENALOG
3
DERMATOP
3
LOCOID
3
DESONATE
3
LOCOID
LIPOCREAM
3
desonide
1
LUXIQ
3
DESOWEN
3
mometasone
1
desoximetasone
1
NUCORT
3
diflorasone
1
OLUX
3
PA; QL
DIPROLENE
3
OLUX-E
3
PA; QL
DIPROLENE AF
3
PANDEL
3
ELOCON
3
PEDIADERM HC
3
PEDIADERM TA
3
prednicarbate
1
PA
PA
QL
46
ST
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
PSORCON
3
ELIMITE
3
scalacort
1
EURAX
2
SCALACORT DK
3
lindane
1
SYNALAR
3
LYCELLE
3
SYNALAR
CREAM KIT
3
malathion
1
NATROBA
3
SYNALAR
OINTMENT KIT
3
OVIDE
3
SYNALAR TS
3
permethrin
1
TEMOVATE
3
PA
SKLICE
3
TEMOVATE E
3
PA
spinosad
1
TEXACORT
3
ULESFIA
3
TOPICORT
TOPICAL
OINTMENT
3
TOPICORT
TOPICAL
SPRAY,NONAEROSOL
2
triamcinolone
acetonide
1
trianex
1
triderm
Restrictions /
Limits
Diagnostics & Miscellaneous Agents
Antidotes
ATROPEN
3
DUODOTE
3
PA
Irrigating Solutions
lactated ringers
1
neomycin-polymyxin
b gu
1
PA
1
NEOSPORIN GU
IRRIGANT
3
PA
ULTRAVATE
3
PHYSIOLYTE
3
ULTRAVATE X
3
3
VANOS
3
ST
PHYSIOSOL
IRRIGATION
VERDESO
3
ST
ringers
1
SORBITOL
3
SORBITOLMANNITOL
3
tis-u-sol
1
VASHE WOUND
THERAPY
3
Topical Enzymes
SANTYL
3
trypsin-balsamcastor oil
1
vasolex
1
XENADERM
3
Topical Scabicides / Pediculicides
Miscellaneous Agents
acamprosate
1
47
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
acetic acid
1
indocyanine green
1
ACTONEL
3
INFASURF
3
ADAGEN
3
JADENU
3
AGRYLIN
3
1
alendronate
1
levocarnitine (with
sugar)
AMPHADASE
3
levocarnitine
intravenous
1
anagrelide
1
levocarnitine oral
1
ANTABUSE
3
LIPOCHOL PLUS
3
ARALAST NP
3
LITHOSTAT
3
bd pre-filled normal
saline
1
METOPIRONE
3
BUPHENYL
3
midodrine
1
caffeine citrated
1
monoject 0.9%
sodium chloride
1
CARBAGLU
3
3
monoject prefill
advanced ns
1
CARNITOR
(SUGAR-FREE)
3
monoject prefill
saline flush
1
CARNITOR
INTRAVENOUS
normal saline flush
1
CARNITOR ORAL
3
NORTHERA
3
LA; QL
cevimeline
1
ORFADIN
3
PA
CHEMET
3
pilocarpine hcl
1
CHOLOGRAFIN
MEGLUMINE
3
PROLASTIN-C
3
disulfiram
1
RADIOGARDASE
3
etidronate disodium
1
RAVICTI
3
PA; LA
EVOXAC
3
RECLAST
3
PA; LA
EXJADE
3
RILUTEK
3
FERRIPROX
3
riluzole
1
FERRLECIT
3
PA
risedronate
1
GLASSIA
3
PA; LA
SALAGEN
3
HYLENEX
3
PA
SINOGRAFIN
3
ic green
1
sodium chlor 0.9%
bacteriostat
1
INCRELEX
3
PA
PA
PA; LA
PA
LA
PA
PA; LA
PA; LA
48
PA
PA
PA
PA
Drug Name
Tier
Restrictions /
Limits
sodium chloride 0.9
% injection solution
1
sodium chloride 0.9
% injection syringe
1
SODIUM
CHLORIDE 0.9 %
INJECTION
SYRINGE, WITH
SWAB CAP
3
sodium chloride 0.9
% intravenous
1
sodium ferric
gluconat-sucrose
1
PA
sodium
phenylbutyrate
1
PA
SOLIRIS
3
PA; LA
SURVANTA
3
SWABFLUSH
3
SYPRINE
3
syrex sodium
chloride 0.9%
1
THIOLA
PA
Drug Name
Tier
NICORETTE
0
ACA; OTC
nicotine
0
ACA; OTC
NICOTINE
(POLACRILEX)
0
ACA; OTC
NICOTROL
0
ACA
NICOTROL NS
0
ACA
QUIT 2
0
ACA; OTC
QUIT 4
0
ACA; OTC
ZYBAN
3
Ear, Nose & Throat Medications
Miscellaneous Agents
ASTEPRO
3
ATROVENT
3
azelastine
1
BACTROBAN
NASAL
3
CLINPRO 5000
3
DEBACTEROL
3
3
denta 5000 plus
1
water for irrigation,
sterile
1
dentagel
1
EPISIL
3
XURIDEN
3
PA; LA
FIRST-BXN
3
ZEMAIRA
3
PA; LA
FIRST-DUKE'S
3
zoledronic acidmannitol-water
1
PA; LA
FIRST-MARY'S
MOUTHWASH
3
FIRSTMOUTHWASH
BLM
3
fluoridex daily
defense
1
FLUORIDEX
SENSITIVITY
RELIEF
3
GELCLAIR
3
PA
Smoking Deterrents
CHANTIX
0
ACA
CHANTIX
CONTINUING
MONTH BOX
0
ACA
CHANTIX
STARTING
MONTH BOX
0
ACA
NICODERM CQ
0
ACA; OTC
Restrictions /
Limits
49
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
GELX
3
acetic acid
1
ipratropium bromide
1
1
MUCOTROL
3
acetic acidaluminum acetate
MUGARD
3
antipyrinebenzocaine
1
nafrinse
1
AURAX
3
olopatadine
1
auroguard
1
ORAFATE
3
CETRAXAL
3
oralone
1
ciprofloxacin hcl
1
ORAMAGICRX
3
cortane-b aqueous
1
PATANASE
3
CRESYLATE
3
pilocarpine hcl
1
DERMOTIC OIL
3
PREVIDENT
3
exotic-hc
1
PREVIDENT 5000
BOOSTER PLUS
3
fluocinolone
acetonide oil
1
PREVIDENT 5000
DRY MOUTH
3
hydrocortisoneacetic acid
1
PREVIDENT 5000
ENAMEL
PROTECT
3
ofloxacin
1
3
PREVIDENT 5000
SENSITIVE
3
OTIC CARE
(ANTIPYRINE)
oticin
1
PROTHELIAL
3
otomax-hc
1
Q-CARE RX Q4
3
otozin
1
REMESENSE
3
Otic Steroid / Antibiotic
SALAGEN
3
CIPRO HC
3
sf
1
CIPRODEX
3
sf 5000 plus
1
COLY-MYCIN S
3
sodium fluoride
1
1
triamcinolone
acetonide
1
neomycinpolymyxin-hc
TYZINE
3
ST
ST
LA
Restrictions /
Limits
Endocrine/Diabetes
Adrenal Hormones
Miscellaneous Otic Preparations
ACTHAR H.P.
3
acetasol hc
CORTEF
3
1
50
PA; LA; QL
Drug Name
Tier
cortisone
1
CORTROSYN
3
cosyntropin injection
Restrictions /
Limits
Drug Name
Tier
TRIESENCE (PF)
3
PA
veripred 20
1
1
PA
Antithyroid Agents
COSYNTROPIN
INTRAVENOUS
3
PA
methimazole
1
propylthiouracil
1
deltasone
1
SSKI
3
dexamethasone
1
TAPAZOLE
3
dexamethasone
intensol
1
DEXPAK 10 DAY
2
DEXPAK 13 DAY
2
DEXPAK 6 DAY
2
fludrocortisone
1
hydrocortisone
1
MEDROL (PAK)
3
MEDROL ORAL
TABLET 16 MG, 32
MG, 4 MG, 8 MG
3
MEDROL ORAL
TABLET 2 MG
2
methylprednisolone
1
millipred dp
1
MILLIPRED ORAL
SOLUTION
Restrictions /
Limits
Blood Glucose Monitoring Devices &
Supplies
ACCU-CHEK
ADVANTAGE
TEST
2
OTC
ACCU-CHEK
AVIVA
2
OTC; QL
ACCU-CHEK
AVIVA PLUS
TEST STRP
2
OTC; QL
ACCU-CHEK
COMPACT TEST
2
OTC; QL
ACCU-CHEK
SMARTVIEW
TEST STRIP
2
OTC; QL
2
OTC; QL
3
ACCUTREND
GLUCOSE
3
ST; OTC; QL
millipred oral tablet
1
ACURA TEST
STRIPS
ORAPRED
3
3
ST; OTC
ORAPRED ODT
3
ADVANCED
GLUC METER
TEST STRIP
PEDIAPRED
3
3
ST; OTC; QL
prednisolone
1
ADVOCATE REDICODE
prednisolone sodium
phosphate
1
ADVOCATE TEST
STRIPS
3
ST; OTC; QL
prednisone
1
AGAMATRIX
AMP TEST STRIPS
3
ST; OTC
prednisone intensol
1
ASSURE 4 STRIPS
3
ST; OTC; QL
RAYOS
3
51
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
ASSURE
PLATINUM
3
ST; OTC; QL
EASY TRAK
GLUCOSE TEST
3
ST; OTC; QL
ASSURE PRISM
MULTI STRIP
3
ST; OTC
EASYGLUCO
PLUS
3
ST; OTC
BG-STAR
3
ST; OTC; QL
3
ST; OTC; QL
BIONIME
RIGHTEST TEST
STRIPS
3
ST; OTC; QL
EASYGLUCO
TEST
EASYMAX
3
ST; OTC; QL
ST; OTC
3
ST; OTC; QL
ELEMENT
COMPACT TEST
STRIPS
3
BLOOD GLUCOSE
TEST
BREEZE 2 TEST
STRIPS
3
ST; OTC; QL
ELEMENT TEST
STRIPS
3
ST; OTC; QL
CARESENS N
TEST STRIPS
3
ST; OTC
3
ST; OTC; QL
CLEVER CHOICE
MICRO TEST
STRIP
3
ST; OTC; QL
EMBRACE
BLOOD GLUCOSE
SYSTEM
EMBRACE EVO
TEST STRIPS
3
ST; OTC
CLEVER CHOICE
PRO
3
ST; OTC; QL
EMBRACE PRO
TEST STRIPS
3
ST; OTC
CLEVER CHOICE
TEST STRIPS
3
ST; OTC; QL
EVENCARE G2
3
ST; OTC; QL
3
ST; OTC; QL
CLEVER CHOICE
VOICE+ TEST
3
ST; OTC; QL
EVENCARE G3
TEST
ST; OTC
3
ST; OTC; QL
EVENCARE MINI
GLUCOSE TEST
STR
3
CONTOUR NEXT
STRIPS
CONTOUR TEST
STRIPS
3
ST; OTC; QL
EVOLUTION TEST
STRIPS
3
ST; OTC; QL
CONTROL G3
3
ST; OTC; QL
3
ST; OTC; QL
DIATRUE PLUS
TEST STRIP
3
ST; OTC
EZ SMART PLUS
TEST
EZ SMART TEST
3
ST; OTC; QL
EASY PLUS II
TEST
3
ST; OTC
FIFTY50 TEST
STRIP
3
ST; OTC; QL
EASY STEP
3
ST; OTC
FORA D10
3
ST; OTC
EASY TALK
GLUCOSE TEST
3
ST; OTC; QL
FORA D15G
3
ST; OTC; QL
FORA D20
3
ST; OTC; QL
EASY TOUCH
TEST STRIP
3
FORA D40-G31
TEST STRIPS
3
PA; OTC; QL
ST; OTC; QL
52
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
FORA G20
3
ST; OTC; QL
GLUCOCARD
EXPRESSION
3
ST; OTC; QL
FORA G30A
3
ST; OTC; QL
FORA GD50 TEST
STRIPS
3
ST; OTC
GLUCOCARD
SHINE TEST
STRIPS
3
ST; OTC
FORA TEST STRIP
3
ST; OTC; QL
GLUCOCARD
VITAL SENSOR
3
ST; OTC; QL
FORA TN'G VOICE
TEST STRIPS
3
PA; OTC
FORA V10
3
ST; OTC
3
ST; OTC; QL
ST; OTC
GLUCOCARD
VITAL TEST
STRIPS
FORA V12
GLUCOSE
3
3
ST; OTC; QL
3
ST; OTC; QL
GLUCOCOM
GLUCOSE
FORA V20
FORACARE GD20
3
ST; OTC; QL
GM100
3
ST; OTC; QL
FORACARE GD40
3
ST; OTC; QL
GMATE TEST
STRIPS
3
ST; OTC
FORTISCARE
GLUCOSE TEST
STRIPS
3
ST; OTC
HEALTHPRO
TEST STRIPS
3
ST; OTC
FREESTYLE
INSULINX
2
OTC; QL
INFINITY TEST
STRIPS
3
ST; OTC; QL
FREESTYLE
INSULINX TEST
STRIPS
2
OTC; QL
LIBERTY TEST
3
ST; OTC; QL
MAXIMA
3
ST; OTC; QL
ST; OTC
2
OTC; QL
MICRO BLOOD
GLUCOSE
3
FREESTYLE LITE
STRIPS
ST; OTC; QL
2
OTC
MICRODOT
BLOOD GLUCOSE
SYSTEM
3
FREESTYLE
PRECISION NEO
STRIPS
ST; OTC; QL
2
OTC; QL
MYGLUCOHEALT
H
3
FREESTYLE TEST
G-4 TEST
3
ST; OTC; QL
3
ST; OTC; QL
GE100 BLOOD
GLUCOSE TEST
STRIP
3
ST; OTC; QL
NEUTEK 2TEK
TEST STRIPS
NOVA MAX
GLUCOSE TEST
3
ST; OTC; QL
GENSTRIP TEST
STRIP
3
ST; OTC
3
ST; OTC
GLUCO NAVII
TEST STRIP
3
ST; OTC
ON CALL
EXPRESS TEST
STRIP
3
ST; OTC; QL
GLUCOCARD 01
SENSOR PLUS
3
ST; OTC
ON CALL PLUS
TEST STRIP
53
Drug Name
Tier
Restrictions /
Limits
Drug Name
ON CALL VIVID
TEST STRIP
3
ST; OTC; QL
SMART SENSE
TEST STRIPS
3
ST; OTC
ONETOUCH
ULTRA TEST
3
ST; OTC; QL
SMARTEST TEST
3
ST; OTC; QL
3
ST; OTC; QL
ONETOUCH
VERIO
3
ST; OTC; QL
SOLUS V2 TEST
STRIPS
ST; OTC; QL
3
OTC; QL
SURE-TEST
EASYPLUS MINI
3
OPTIUM EZ
OPTIUM TEST
3
OTC; QL
3
ST; OTC; QL
OPTUMRX
3
ST; OTC
TELCARE TEST
STRIPS
PHARMACIST
CHOICE
3
ST; OTC; QL
TEST N'GO TEST
3
ST; OTC
3
ST; OTC
PRECISION PCX
PLUS TEST
2
OTC; QL
TRUE METRIX
GLUCOSE TEST
STRIP
PRECISION PCX
TEST
2
OTC; QL
TRUETEST TEST
STRIPS
3
ST; OTC
PRECISION POINT
OF CARE TEST
2
OTC; QL
TRUETRACK
TEST
3
ST; OTC; QL
PRECISION Q-I-D
TEST
2
OTC; QL
ULTIMA TEST
STRIPS
3
ST; OTC
PRECISION XTRA
TEST
2
OTC; QL
ULTRATRAK
3
ST; OTC
3
ST; OTC; QL
PREMIUM V10
3
ST; OTC; QL
ULTRATRAK
ULTIMATE
PRODIGY
3
ST; OTC; QL
UNISTRIP1 TEST
STRIP
3
ST; OTC
PRODIGY NO
CODING
3
ST; OTC; QL
WAVESENSE
JAZZ
3
ST; OTC
QUINTET AC
3
ST; OTC
3
ST; OTC; QL
REFUAH PLUS
3
ST; OTC; QL
WAVESENSE
PRESTO
RELION
CONFIRM-MICRO
3
ST; OTC; QL
Diabetes, Supplies, & Durable
Medical Equipment
RELION PRIME
TEST STRIPS
3
ST; OTC; QL
GLUCAGEN
DIAGNOSTIC KIT
3
QL
REVEAL TEST
STRIP
3
ST; OTC; QL
GLUCAGON HCL
3
QL
RIGHTEST GS550
TEST STRIPS
3
ST; OTC; QL
Glucose Elevating Agents
54
GLUCAGEN
HYPOKIT
Tier
3
Restrictions /
Limits
QL
Drug Name
Tier
Restrictions /
Limits
Drug Name
QL
ACTI-LANCE
LANCETS
2
OTC
ADJUSTABLE
LANCING DEVICE
2
OTC
Insulin Syringes/Miscellaneous
Durable Medical Equ
ADVANCED
GLUCOSE METER
3
OTC
1ST TIER UNIFINE
PENTIPS
2
OTC
ADVANCED
LANCING DEVICE
2
OTC
1ST TIER UNILET
COMFORTOUCH
2
OTC
ADVANCED
TRAVEL
LANCETS
3
OTC
ACCU-CHEK
AVIVA CONNECT
METER
2
ADVOCATE
BLOOD GLUCOSE
MONITOR
3
OTC
ACCU-CHEK
AVIVA PLUS
METER
0
ADVOCATE
LANCET
2
OTC
ACCU-CHEK
COMBO SYSTEM
3
ADVOCATE PEN
NEEDLES
2
OTC
ACCU-CHEK
FASTCLIX
2
OTC
ADVOCATE
RAPID-SAFE
LANCING
3
OTC; QL
ACCU-CHEK
NANO
0
OTC
3
OTC
ACCU-CHEK
SAFE-T-PRO
3
OTC
ADVOCATE REDICODE GLU
MONITOR
OTC
3
OTC
AGAMATRIX
AMP GLUC
MONITOR SYS
3
ACCU-CHEK
SMARTVIEW
CONTRL SOL
OTC
2
OTC; QL
ALTERNATE SITE
LANCET
2
ACCU-CHEK
SOFTCLIX
LANCET DEV
ALTERNATE SITE
LANCING DEVICE
2
OTC
ACCU-CHEK
SOFTCLIX
LANCETS
2
OTC
AQUA LANCE
LANCING DEVICE
2
OTC
ACCU-CHEK
VOICEMATE
2
OTC
ASSURE LANCE
2
OTC
3
OTC
ACCUTREND
GLUCOSE
CONTROL
3
OTC
ASSURE LANCE
PLUS
ASSURE
PLATINUM
3
OTC
GLUCAGON
EMERGENCY KIT
(HUMAN)
2
PROGLYCEM
3
OTC
Tier
Restrictions /
Limits
55
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
BD
PRECISIONGLIDE
NON-STERILE
2
BD QUINCKE
SPINAL NEEDLE
3
Restrictions /
Limits
ASSURE PRISM
MULTI METER
3
OTC
AUTOJECT 2
INJECTION
DEVICE
2
OTC
AUTO-LANCET
MINI
2
OTC
BD SAFETYGLIDE
NEEDLE
2
AUTOLET
IMPRESSION
LANC DEV
2
OTC
BD SPECIALTY
USE NEEDLES
2
2
OTC
AUTOLET
LANCING DEVICE
2
OTC
BD ULTRA FINE
LANCETS
OTC
2
OTC
BD ULTRA-FINE
NANO PEN
NEEDLES
2
AUTOPEN 2 TO 32
UNITS
BD AUTOSHIELD
PEN NEEDLE
2
OTC
BD WHITACRE
SPINAL NEEDLE
3
BD CURVED
TONSIL
REUSABLE
2
BD YALE
REUSABLE REG
METAL
2
BD ECLIPSE
2
3
OTC
BD FILTER
NEEDLE-5
MICRON
2
BIONIME
RIGHTEST GM300
SYSTEM
3
OTC
BD INSULIN PEN
NEEDLE UF
SHORT
2
BLOOD-GLUCOSE
METER
BLUNT NEEDLE,
DISPOSABLE
3
BD INTEGRA
NEEDLE
2
2
OTC
BD LANCET
DEVICE
2
BULLSEYE MINI
SAFETY
LANCETS
2
OTC
BD
MICROTAINER
LANCET
3
CAREFINE PEN
NEEDLE
CAREONE THIN
LANCET
2
OTC
BD NOKOR
ADMIX NEEDLE
2
CARESENS N
3
OTC
OTC
2
CARESENS N
VOICE
3
BD
PRECISIONGLIDE
CLEVER CHEK
BLOOD GLUCOSE
3
OTC
OTC
OTC
56
OTC
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
CLEVER CHEK
LANCETS
2
OTC
EASY COMFORT
LANCETS
2
OTC
CLEVER CHOICE
GLUCOSE
MONITOR
3
OTC
EASY COMFORT
PEN NEEDLES
2
OTC
OTC; QL
3
OTC
EASY MINI EJECT
LANCING DEVICE
3
CLEVER CHOICE
MICRO
3
OTC
CLEVER CHOICE
PRO
3
OTC
EASY PLUS II
BLOOD GLUCOSE
MET
CLICKFINE
2
OTC
3
OTC
COAGUCHEK
LANCETS
2
OTC
EASY STEP
BLOOD GLUCOSE
METER
COLOR LANCETS
2
OTC
3
OTC
COMFORT EZ PEN
NEEDLES
2
OTC
EASY TALK
BLOOD GLUCOSE
METER
3
COMFORT
LANCETS
3
OTC
EASY TOUCH
FLIPLOCK
NEEDLE
CONTOUR LINK
3
OTC
3
CONTOUR NEXT
EZ METER
3
OTC
EASY TOUCH
GLUCOSE
MONITOR
CONTOUR NEXT
METER
3
OTC
EASY TOUCH
HYPODERMIC
NEEDLE
3
CONTOUR NEXT
USB METER
3
OTC
EASY TOUCH
LANCING DEVICE
2
OTC
CONTROL
MONITORING
SYSTEM
3
OTC
EASY TRAK
BLOOD GLUCOSE
METER
3
OTC
DIATRUE PLUS
BLOOD GLUCOSE
MET
3
OTC
EASYGLUCO
MONITORING
SYSTEM
3
OTC
DROPLET
LANCETS
2
OTC
3
OTC
DROPLET
LANCING DEVICE
2
OTC
EASYMAX L
BLOOD GLUCOSE
METER
EASYMAX NG
3
OTC
DROPLET PEN
NEEDLE
2
OTC
3
OTC
EASY CLICK
LANCING DEVICE
2
OTC
EASYMAX V
SPEAKING
GLUCOSE SYS
OTC
57
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
OTC
FINGERSTIX
LANCETS
2
OTC
FIRST CHOICE
LANCETS THIN
2
OTC
FLOW-EZE
VENTED NEEDLE
2
FORA D20
3
OTC
FORA G20
3
OTC
OTC
FORA G30A
3
OTC
3
OTC
OTC
FORA GD50
BLOOD GLUCOSE
SYSTEM
FORA LANCING
DEVICE
2
OTC
FORA TEST N'GO
VOICE METER
3
OTC
EASYMAX V2
BLOOD GLUCOSE
METER
3
ELEMENT
COMPACT
GLUCOSE METER
3
ELEMENT
COMPACT V
GLUCOSE MTR
3
ELEMENT PLUS
BLOOD GLUCOSE
KIT
3
EMBRACE
BLOOD GLUCOSE
SYSTEM
3
EMBRACE PRO
GLUCOSE METER
3
ENLITE SYSTEM
3
OTC
3
OTC
FORA TN'G VOICE
METER
3
EVENCARE G2
EVENCARE G3
GLUCOSE METER
3
OTC
FORA V10
3
OTC
3
PA; OTC
EVOLUTION
BLOOD GLUCOSE
METER
3
OTC
FORA V10-V12D10-D20
3
OTC
EXEL
HYPODERMIC
NEEDLES
2
FORA V12 BLOOD
GLUCOSE
SYSTEM
FORA V20
3
OTC
e-z ject lancets
1
OTC
FORA V30A
3
OTC
EZ SMART
LANCETS
3
OTC
FORACARE GD20
GLUCOSE METER
3
OTC
EZ SMART PLUS
SYSTEM
3
OTC
FORACARE
GD40A GLUCOSE
METER
3
OTC
EZ SMART
SYSTEM
3
OTC
3
OTC
FIFTY50 SAFETY
SEAL LANCETS
2
OTC
FORACARE
GD40B GLUCOSE
METER
2
OTC
FINE 30
UNIVERSAL
LANCETS
2
OTC
FORACARE
LANCETS
OTC
OTC
OTC
58
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
OTC
GLUCOCOM
BLOOD GLUCOSE
3
OTC
GLUCOCOM
LANCETS
2
OTC
GM100
3
OTC
GMATE LANCETS
3
OTC
FORTISCARE
BLOOD GLUCOSE
SYST
3
FREESTYLE
FLASH SYSTEM
0
OTC
FREESTYLE
FREEDOM
0
OTC
FREESTYLE
FREEDOM LITE
0
OTC
GMATE LANCING
DEVICE
3
OTC; QL
FREESTYLE
INSULINX
0
OTC
GMATE SMART
METER
3
OTC
FREESTYLE
LANCETS
2
OTC
GMATE SMART
STARTER
3
OTC
FREESTYLE LITE
METER
0
OTC
GMATE VOICE
METER
3
OTC
FREESTYLE
PRECISION NEO
METER
0
OTC
HEALTHPRO
GLUCOSE
MONITOR
3
OTC
FREESTYLE
SIDEKICK II
0
OTC
HEALTHY
ACCENTS
AUTOLET
2
OTC
FREESTYLE
SYSTEM KIT
0
OTC
2
OTC
FREESTYLE
UNISTIK 2
2
OTC
HEALTHY
ACCENTS
UNIFINE PENTIP
2
OTC
GE100 BLOOD
GLUCOSE
SYSTEM
3
HEALTHY
ACCENTS UNILET
LANCET
1
GLUCO NAVII
GLUCOSE
MONITOR
3
huber safety needles
(disp.)
HUMAPEN
LUXURA HD
3
GLUCOCARD 01
METER
3
OTC
HYPOLANCE AST
LANCING
2
OTC
GLUCOCARD
EXPRESSION
3
OTC
INCONTROL
LANCING DEVICE
2
OTC
GLUCOCARD
SHINE METER
3
OTC
INCONTROL PEN
NEEDLE
2
OTC
GLUCOCARD
VITAL
3
OTC
OTC
OTC
59
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
OTC
MEDLANCE PLUS
LANCETS
2
OTC
2
OTC
OTC
MICRO THIN
LANCETS
3
OTC
INCONTROL
SUPER THIN
LANCETS
2
INCONTROL
ULTRA THIN
LANCETS
2
INFINITY
STARTER KIT
3
OTC
MICRODOT
BLOOD GLUCOSE
SYSTEM
OTC
2
OTC
MICROLET
LANCET
2
INJECT EASE
LANCETS
2
OTC
INSUPEN
2
OTC
MINI LANCING
DEVICE
INVACARE
LANCETS
2
OTC
MINI ULTRATHIN II
2
OTC
KINNEY BRAND
LANCETS
3
OTC
3
LANCETS
2
OTC
MONOJECT
BLOOD
COLLECTION
LANCETS 30
GAUGE
3
OTC
MONOJECT
HYPODERMIC
NEEDLES
2
LANCETS,THIN
3
OTC
2
LANCETS,THIN 28
GAUGE
2
OTC
MONOJECT
MEDICATION
TRANSF NDL
LANCING DEVICE
WITH LANCETS
2
OTC
MONOLET
LANCETS
2
OTC
LANCING
SYSTEM
3
OTC; QL
MONOLET THIN
LANCETS
2
OTC
LANZO LANCING
DEVICE
3
OTC
MULTI-DRAW
NEEDLE
2
LIBERTY BLOOD
GLUCOSE METER
3
OTC
MULTI-LANCET
DEVICE 2
3
OTC
LITE TOUCH
LANCETS
2
OTC
MYGLUCOHEALT
H
3
OTC
LOCAL
ANESTHESIA
NEEDLE 22GX2"
3
MYGLUCOHEALT
H LANCETS
2
OTC
2
OTC
NEEDLES, HUBER
DISPOSABLE
2
MAJOR COMFORT
MEDISENSE THIN
LANCETS
2
OTC
NOKOR NEEDLE
2
60
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
OTC
ONETOUCH
ULTRA2
3
OTC
ONETOUCH
ULTRAMINI
3
OTC
ONETOUCH
ULTRASOFT
LANCETS
2
OTC
ONETOUCH
VERIO FLEX
3
OTC
ONETOUCH
VERIO IQ METER
3
OTC
ONETOUCH
VERIO SYNC
3
OTC
3
OTC
NOVA MAX
BLOOD GLUCOSE
METER
3
NOVA SAFETY
LANCETS
2
OTC
NOVA SUREFLEX
LANCETS
2
OTC
NOVOFINE 32
2
OTC
NOVOFINE
AUTOCOVER
2
OTC
NOVOFINE PLUS
2
NOVOPEN ECHO
3
NOVOTWIST
2
OTC
ON CALL
EXPRESS METER
3
OTC
ONETOUCH
VERIO SYSTEM
OTC
2
OTC
ON-THE-GO
LANCETS
2
ON CALL LANCET
ON CALL
LANCING DEVICE
2
OTC
OPTUMRX
3
OTC
2
OTC
PARASYMPATH
NERVE NDL 20 G
X6"
3
ON CALL PLUS
LANCET
ON CALL PLUS
LANCING DEVICE
2
OTC
PEN NEEDLE
2
OTC
OTC
3
OTC
PEN NEEDLE,
DIABETIC
2
ON CALL PLUS
METER
PENTIPS
2
OTC
ON CALL VIVID
METER
3
OTC
PENTIPS PEN
NEEDLE
2
OTC
ON CALL VIVID
PAL METER
3
OTC
3
OTC
ONETOUCH
DELICA LANC
DEVICE
2
OTC
PHARMACIST
CHOICE
GLUCOSE SYS
PHASEAL
PROTECTOR
3
ONETOUCH
FINEPOINT
LANCETS
2
OTC
POLY HUB
NEEDLE
2
ONETOUCH
SURESOFT
LANCING DEV
2
OTC
PRECISION XTRA
MONITOR
2
OTC
OTC
61
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
PREMIUM BLOOD
GLUCOSE
MONITOR
3
OTC
RELION MICRO
GLUCOSE
MONITOR
3
OTC
PREMIUM V10
3
OTC
RELION NEEDLES
2
OTC
PRESSURE
ACTIVATED
LANCETS
2
OTC
RELION PEN
NEEDLES
2
OTC
3
OTC
PRESTO PRO
BLOOD GLUCOSE
METER
3
RELION PRIME
METER
RELION THIN
LANCETS
2
OTC
PRODIGY
AUTOCODE
METER
3
OTC
RELION ULTRA
THIN PLUS
LANCETS
2
OTC
PRODIGY
AUTOCODE
MONITOR SYST
3
OTC
REVEAL BLOOD
GLUCOSE METER
3
OTC
PRODIGY
LANCETS
2
OTC
RIGHTEST GD500
LANCING DEVICE
2
OTC
PRODIGY
LANCING DEVICE
2
OTC
RIGHTEST GL300
LANCETS
2
OTC
PRODIGY
POCKET METER
3
OTC
RIGHTEST GM550
SYSTEM
3
OTC
PRODIGY TWIST
TOP LANCET
2
OTC
SAFETY
LANCETS
2
OTC
PRODIGY VOICE
GLUCOSE METER
3
OTC
SAFETY SEAL
LANCETS
2
OTC
QUINTET BLOOD
GLUCOSE METER
3
OTC
SAFETY-LET
LANCETS
2
OTC
REFUAH PLUS
GLUCOSE
MONITOR
3
OTC; QL
SINGLE-LET
3
OTC
SMART SENSE
LANCETS
2
OTC
RELIAMED
LANCET
3
OTC
3
OTC
RELIAMED MINI
LANCING DEVICE
2
OTC
SMART SENSE
MONITORING
SYSTEM
2
OTC
RELIAMED
SAFETY SEAL
LANCETS
2
SMARTDIABETES
VANTAGE
SMARTEST EJECT
3
OTC
2
OTC
RELION CONFIRM
3
SMARTEST
LANCET
OTC
OTC
OTC
62
Drug Name
Tier
Restrictions /
Limits
Drug Name
SMARTEST
PERSONA
STARTER
3
SMARTEST
PRONTO
STARTER
3
OTC
SMARTEST
PROTEGE
3
OTC
SNAP INSULIN
PUMP
CONTROLLER
3
SNAP INSULIN
PUMP-INFUSION
SET
3
SOFT TOUCH
LANCETS
2
SOLUS V2
AUDIBLE METER
Tier
Restrictions /
Limits
OTC
SURE-LANCE
2
OTC
SURE-PEN
LANCING DEVICE
2
OTC
SURE-TEST
EASYPLUS MINI
METER
3
OTC
SURE-TOUCH
LANCET
2
OTC
SURGUARD2
SAFETY
3
T:SLIM
2
T:SLIM G4
3
TECHLITE
LANCETS
2
OTC
OTC
2
OTC
3
OTC
TECHLITE PEN
NEEDLE
TELCARE BGM
3
OTC
SOLUS V2
LANCETS
2
OTC
TELCARE BLOOD
GLUCOSE KIT
3
OTC
SOLUS V2
LANCING DEVICE
2
OTC
3
OTC
STERILANCE TL
3
OTC
TEST N'GO
BLOOD GLUCOSE
SYSTEM
SUPER THIN
LANCETS
2
OTC
TITUS NEEDLE
2
2
OTC
SURE COMFORT
LANCETS
2
OTC
TOPCARE
UNIVERSAL1
LANCET
SURE COMFORT
LANCING PEN
2
OTC
TRUE METRIX
GLUCOSE METER
3
OTC
SURE COMFORT
PEN NEEDLE
2
OTC
3
OTC
SURE EDGE
BLOOD GLUCOSE
METER
3
OTC
TRUE2GO BLOOD
GLUCOSE
SYSTEM
TRUEDRAW
LANCING DEVICE
2
OTC
SURE-FINE PEN
NEEDLES
2
OTC
TRUEPLUS
LANCETS
2
OTC
SUREFLEX
LANCING DEVICE
2
OTC
TRUERESULT
BLOOD GLUCOSE
SYSTM
3
OTC
63
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
TRUETRACK
BLOOD GLUCOSE
SYSTEM
3
OTC
UNILET
COMFORTOUCH
LANCET
2
OTC
TRUETRACK
SMART SYSTEM
3
OTC
2
OTC
ULTICARE PEN
NEEDLE
2
OTC
UNILET
EXCELITE II
LANCET
3
OTC
ULTI-LANCE
2
OTC
UNILET
EXCELITE
LANCET
ULTILET BASIC
LANCETS
2
OTC
UNILET GP
LANCET
2
OTC
ULTILET CLASSIC
LANCETS
3
OTC
UNILET LANCET
2
OTC
ULTILET
LANCETS
2
OTC
UNISTIK 2
DEVICE
2
OTC
ULTILET PEN
NEEDLE
2
OTC
UNISTIK 2
NORMAL
LANCET,DEVICE
2
OTC
ULTILET SAFETY
LANCETS
3
OTC
UNISTIK 3
2
OTC
ULTIMA
MONITOR
3
OTC
UNISTIK 3 EXTRA
LANCET
2
OTC
ULTRA THIN
LANCETS
2
OTC
UNISTIK CZT
LANCET
2
OTC
ULTRA THIN
PLUS LANCETS
2
OTC
UNISTIK SAFETY
3
OTC
3
OTC
ULTRA TLC
LANCETS
3
UNISTIK TOUCH
LANCETS
2
OTC
ULTRALANCE
LANCETS
2
UNIVERSAL 1
LANCETS
VGO 20
3
ULTRA-THIN II
INS PEN NEEDLES
2
VGO 30
3
VGO 40
3
ULTRATRAK
GLUCOSE METER
3
OTC
WAVESENSE AMP
3
OTC
ULTRATRAK
ULTIMATE
3
OTC
WAVESENSE
JAZZ
3
OTC
UNIFINE PENTIPS
2
OTC
WAVESENSE
PRESTO
3
OTC
UNIFINE PENTIPS
PLUS
2
OTC
YALE SPINAL
NEEDLE
3
OTC
OTC
OTC
OTC
64
Drug Name
Tier
Restrictions /
Limits
Insulin Therapy
Drug Name
Tier
Restrictions /
Limits
NOVOLIN R
3
PA
AFREZZA
3
PA
NOVOLOG
3
PA
APIDRA
3
PA
3
PA
APIDRA
SOLOSTAR
3
PA
NOVOLOG
FLEXPEN
3
PA
HUMALOG
2
NOVOLOG MIX
70-30
HUMALOG
KWIKPEN
2
NOVOLOG MIX
70-30 FLEXPEN
3
PA
HUMALOG MIX
50-50
2
NOVOLOG
PENFILL
3
PA
HUMALOG MIX
50-50 KWIKPEN
2
TOUJEO
SOLOSTAR
2
HUMALOG MIX
75-25
2
TRESIBA
FLEXTOUCH U100
3
ST
HUMALOG MIX
75-25 KWIKPEN
2
3
ST
HUMULIN 70/30
2
TRESIBA
FLEXTOUCH U200
HUMULIN 70/30
KWIKPEN
2
Miscellaneous Hormones
HUMULIN N
2
HUMULIN N
KWIKPEN
2
HUMULIN R
2
HUMULIN R U-500
(CONC) KWIKPEN
2
HUMULIN R U-500
(CONCENTRATED
)
2
LANTUS
2
LANTUS
SOLOSTAR
2
LEVEMIR
2
LEVEMIR
FLEXTOUCH
2
NOVOLIN 70/30
3
PA
NOVOLIN N
3
PA
ACTHREL
3
PA
ALDURAZYME
3
PA; LA
ANADROL-50
3
PA
ANDRODERM
3
PA; QL
ANDROGEL
TRANSDERMAL
GEL IN
METERED-DOSE
PUMP
2
PA; QL
ANDROGEL
TRANSDERMAL
GEL IN PACKET 1
% (25
MG/2.5GRAM), 1
% (50 MG/5
GRAM)
3
PA; QL
65
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
PA; QL
ELAPRASE
3
PA; LA
ELELYSO
3
PA
FABRAZYME
3
PA; LA
FIRSTTESTOSTERONE
3
PA
3
ANDROGEL
TRANSDERMAL
GEL IN PACKET
1.62 % (20.25
MG/1.25 GRAM),
1.62 % (40.5
MG/2.5 GRAM)
2
ANDROID
3
PA; QL
androxy
1
PA; QL
FIRSTTESTOSTERONE
MC
AVEED
3
PA
FOLLISTIM AQ
2
PA; LA
AXIRON
3
PA
FORTESTA
3
PA
BRAVELLE
2
PA; LA
fortical
1
cabergoline
1
GANIRELIX
2
PA; LA
calcitonin (salmon)
1
GONAL-F
3
PA; LA
calcitriol
intravenous
1
GONAL-F RFF
3
PA; LA
3
PA; LA
calcitriol oral
1
GONAL-F RFF
REDI-JECT
CERDELGA
3
PA
3
PA
CEREZYME
3
PA
HECTOROL
INTRAVENOUS
CETROTIDE
3
PA; LA
HECTOROL ORAL
3
chorionic
gonadotropin,
human
1
KORLYM
3
PA
KUVAN
3
PA; LA
LUMIZYME
3
PA; LA
clomiphene citrate
1
MENOPUR
2
PA; LA
danazol
1
METHITEST
3
PA; QL
DDAVP NASAL
AEROSOL,SPRAY
3
methyltestosterone
1
PA; QL
DDAVP NASAL
SOLUTION
2
MIACALCIN
3
MYALEPT
3
PA; LA
DDAVP ORAL
3
MYOZYME
3
PA; LA
DEPOTESTOSTERONE
3
NAGLAZYME
3
PA; LA
NATESTO
3
PA
desmopressin
1
NATPARA
3
PA; LA
doxercalciferol
intravenous
1
novarel
1
doxercalciferol oral
1
OVIDREL
3
PA
PA
66
Drug Name
Tier
Restrictions /
Limits
Drug Name
OXANDRIN
3
PA
1
PA; QL
oxandrolone
1
PA
testosterone
transdermal gel in
packet
pamidronate
1
PA; LA
TESTRED
3
PA; QL
PARICALCITOL
HEMODIALYSIS
PORT INJECTION
3
PA
VASOSTRICT
3
PA
VIMIZIM
3
PA; LA
paricalcitol oral
1
VOGELXO
3
PA; QL
PREGNYL
3
VPRIV
3
PA; LA
ROCALTROL
3
ZAVESCA
3
PA; LA
SAMSCA
3
3
PA
SENSIPAR
3
ZEMPLAR
INTRAVENOUS
SOMAVERT
3
ZEMPLAR ORAL
3
STIMATE
3
zoledronic acid
1
PA
STRENSIQ
3
PA
3
LA
STRIANT
3
PA; QL
ZOLEDRONIC
ACID-MANNITOLWATER
SYNAREL
2
PA
ZOMETA
3
PA; LA
TESTIM
3
PA; QL
Non-Insulin Hypoglycemic Agents
TESTONE CIK
3
TESTOPEL
3
testosterone
cypionate
QL
PA; LA
PA; LA
Tier
Restrictions /
Limits
acarbose
1
ACTOPLUS MET
3
QL
1
ACTOPLUS MET
XR
3
ST; QL
testosterone
enanthate
1
ACTOS
3
QL
testosterone
transdermal gel in
metered-dose pump
1.25 gram/ actuation
(1 %)
1
AMARYL
3
AVANDIA
3
ST; QL
BYDUREON
2
ST; QL
BYETTA
2
ST; QL
TESTOSTERONE
TRANSDERMAL
GEL IN
METERED-DOSE
PUMP 10 MG/0.5
GRAM
/ACTUATION
3
chlorpropamide
1
CYCLOSET
3
DUETACT
3
ST
FARXIGA
3
ST
FORTAMET
3
PA
glimepiride
1
PA; LA
PA; QL
PA
67
Drug Name
Tier
glipizide
1
glipizide-metformin
1
GLUCOPHAGE
3
GLUCOPHAGE XR
3
GLUCOTROL
3
GLUCOTROL XL
3
GLUCOVANCE
3
glyburide
1
glyburide
micronized
1
glyburide-metformin
1
GLYNASE
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
metformin oral
tablet,er
gast.retention 24 hr
1
miglitol
1
nateglinide
1
NESINA
3
ST
ONGLYZA
3
ST
OSENI
3
ST
pioglitazone
1
QL
pioglitazoneglimepiride
1
ST
pioglitazonemetformin
1
QL
3
GLYSET
3
PRANDIN
3
GLYXAMBI
3
PA
PRECOSE
3
INVOKAMET
2
ST
repaglinide
1
INVOKANA
2
ST
1
JANUMET
2
repaglinidemetformin
JANUMET XR
2
RIOMET
3
JANUVIA
2
STARLIX
3
JARDIANCE
2
SYMLINPEN 120
3
ST; QL
JENTADUETO
2
SYMLINPEN 60
3
ST; QL
JENTADUETO XR
2
SYNJARDY
2
ST
KAZANO
3
ST
TANZEUM
3
PA
KOMBIGLYZE XR
3
ST
tolazamide
1
metformin oral
tablet
1
tolbutamide
1
TRADJENTA
2
metformin oral
tablet extended
release 24 hr
1
TRULICITY
3
PA
VICTOZA 2-PAK
2
ST; QL
metformin oral
tablet extended
release 24hr
1
VICTOZA 3-PAK
2
ST; QL
XIGDUO XR
3
ST
ST
PA
68
Thyroid Hormones
PA
Drug Name
Tier
ARMOUR
THYROID
2
CYTOMEL
3
levothyroxine
intravenous
1
levothyroxine oral
1
levoxyl
1
liothyronine
intravenous
1
liothyronine oral
1
nature-throid
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
BENTYL ORAL
3
CANTIL
3
CESINEX
3
chlordiazepoxideclidinium
1
CUVPOSA
3
PA; LA
dicyclomine
intramuscular
1
PA
dicyclomine oral
1
1
1
diphenoxylateatropine
np thyroid
1
DONNATAL
3
SYNTHROID
3
3
THYROLAR-1
2
DONNATAL
EXTENTABS
THYROLAR-1/2
2
ed-spaz
1
THYROLAR-1/4
2
FULYZAQ
3
THYROLAR-2
2
GLYCATE
3
THYROLAR-3
2
glycopyrrolate
injection
1
TIROSINT
3
glycopyrrolate oral
1
TRIOSTAT
3
hyoscyamine sulfate
1
unithroid
1
hyosyne
1
westhroid
1
LEVBID
3
WP THYROID
3
3
Gastroenterology
LEVSIN
INJECTION
Antidiarrheals & Antispasmodics
LEVSIN ORAL
3
anaspaz
1
LEVSIN/SL
3
atropine
1
3
belladonna
alkaloids-opium
1
LIBRAX (WITH
CLIDINIUM)
LOMOTIL
3
belladonna-opium
1
loperamide
1
BENTYL
INTRAMUSCULA
R
3
methscopolamine
1
MOTOFEN
3
NULEV
3
PA
PA
PA
PA
PA
PA; QL
PA
PA
69
Drug Name
Tier
opium tincture
1
oscimin
1
oscimin sl
1
oscimin sr
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
ANTIVERT ORAL
TABLET 12.5 MG,
25 MG
3
ANTIVERT ORAL
TABLET 50 MG
2
1
PAMINE FQ
3
anucort-hc
1
paregoric
1
ANUSOL-HC
3
phenohytro
1
3
PA
propantheline
1
ANZEMET
INTRAVENOUS
ROBINUL FORTE
3
ANZEMET ORAL
3
ST; QL
ROBINUL
INJECTION
3
APRISO
3
ASACOL
2
ROBINUL ORAL
3
ASACOL HD
2
SYMAX DUOTAB
3
AURYXIA
3
symax fastabs
1
AZULFIDINE
3
symax-sl
1
3
symax-sr
1
AZULFIDINE ENTABS
balsalazide
1
budesonide
1
calcium acetate
1
PA
Miscellaneous Gastrointestinal
Agents
ACTIGALL
3
AKYNZEO
3
PA; QL
CANASA
2
alosetron
1
QL
CESAMET
3
ALOXI
3
PA
CHENODAL
3
AMITIZA
2
QL
CHOLBAM
3
ANA-LEX KIT
3
CIMZIA
3
PA; LA; QL
ANALPRAM E
3
3
PA; LA; QL
ANALPRAM-HC
2
CIMZIA POWDER
FOR RECONST
ANALPRAM-HC
SINGLES RECTAL
CREAM 1-1 % (4G)
2
COLAZAL
3
colocort
1
3
ANALPRAM-HC
SINGLES RECTAL
CREAM 2.5-1 %
(4G)
3
COLYTE WITH
FLAVOR PACKS
COMPAZINE
3
compro
1
constulose
1
70
PA
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
CORTENEMA
3
gavilyte-n
0
CORTIFOAM
2
generlac
1
CREON
2
GIAZO
3
cromolyn
1
GOLYTELY
3
CYSTADANE
3
granisetron (pf)
1
PA
DELZICOL
2
1
PA
DICLEGIS
3
granisetron hcl
intravenous
DIGEX NF
3
granisetron hcl oral
1
ST; QL
dimenhydrinate
1
granisol
1
PA; QL
DIPENTUM
3
hemmorex-hc
1
dronabinol
1
hydrocortisone
1
droperidol
1
hydrocortisone
acetate
1
eliphos
1
3
PA
hydrocortisonepramoxine
1
EMEND
INTRAVENOUS
KAYEXALATE
3
EMEND ORAL
CAPSULE 125 MG
3
QL
KINEVAC
3
EMEND ORAL
CAPSULE 40 MG,
80 MG
3
kionex
1
KRISTALOSE
3
lactulose
1
EMEND ORAL
CAPSULE,DOSE
PACK
3
LIALDA
2
1
ENTOCORT EC
3
rectal cream
ENTYVIO
3
1
FOSRENOL
3
LIDOCAINE HCLHYDROCORTISO
N AC RECTAL
GEL
3
enulose
gastrinex nf
1
3
GATTEX 30-VIAL
3
PA; LA
rectal kit
1
GASTROCROM
gavilyte-c
0
ACA
lidocainehydrocortisone-aloe
1
gavilyte-g
0
ACA
LINZESS
2
QL
gavilyte-h and
bisacodyl
0
ACA
LOTRONEX
3
QL
QL
PA
PA
QL
PA; LA
ACA
PA
71
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
MAGNEBIND 400
3
PENTASA
3
MARINOL
3
PERTZYE
3
meclizine
1
PHOSLO
3
mesalamine
1
PHOSLYRA
3
mesalamine with
cleansing wipe
1
pramcort
1
PREPOPIK
3
metoclopramide hcl
injection
1
prochlorperazine
1
metoclopramide hcl
oral
1
prochlorperazine
edisylate
1
METOZOLV ODT
3
prochlorperazine
maleate
1
MOVANTIK
3
PROCORT
3
MOVIPREP
3
PROCTOCORT
3
NOVACORT
3
PROCTOFOAM HC
3
NULYTELY WITH
FLAVOR PACKS
3
procto-med hc
1
OCALIVA
3
procto-pak
1
ondansetron
1
proctosol hc
1
ondansetron hcl (pf)
1
PA
proctozone-hc
1
ondansetron hcl
intravenous
1
PA
RECTIV
3
REGLAN
3
ondansetron hcl oral
solution
1
RELISTOR
3
PA
REMICADE
3
PA; LA
tablet 24 mg
1
RENAGEL
2
QL
tablet 4 mg, 8 mg
1
RENVELA
2
ROWASA
3
OSMOPREP
3
SANCUSO
3
PANCREAZE
3
1
peg 3350electrolytes
0
sodium polystyrene
sulfonate oral
1
peg-3350 with flavor
packs
0
ACA
sodium polystyrene
sulfonate rectal
enema 30 gram/120
ml
peg-electrolyte soln
0
ACA
peg-prep
0
ACA
PA
PA
PA; LA
QL
ACA
72
PA
ST; QL
Drug Name
Tier
SODIUM
POLYSTYRENE
SULFONATE
RECTAL ENEMA
50 GRAM/200 ML
3
sps
1
SUCLEAR
3
SUCRAID
3
sulfasalazine
1
SUPREP BOWEL
PREP KIT
3
TIGAN
INTRAMUSCULA
R
3
TIGAN ORAL
3
TRANSDERMSCOP
3
trilyte with flavor
packets
0
trimethobenzamide
1
UCERIS
3
ULTRESA
3
URSO 250
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
ZENPEP ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
10,000-34,000 55,000 UNIT,
15,000-51,000 82,000 UNIT,
20,000-68,000 109,000 UNIT,
25,000-85,000136,000 UNIT,
3,000-10,00016,000 UNIT
2
ZENPEP ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
40,000-136,000218,000 UNIT,
5,000-17,000 27,000 UNIT
3
ZOFRAN (AS
HYDROCHLORID
E) INTRAVENOUS
3
3
3
ZOFRAN (AS
HYDROCHLORID
E) ORAL
URSO FORTE
3
ZOFRAN ODT
3
ursodiol
1
ZUPLENZ
3
PA; QL
VARUBI
3
QL
VELPHORO
3
PA
ACIPHEX
3
ST; QL
VELTASSA
3
PA
ST; QL
2
ACIPHEX
SPRINKLE
3
VIBERZI
VIOKACE
3
amoxicilclarithromylansopraz
1
carafate oral
suspension
1
CARAFATE ORAL
TABLET
3
PA; LA
PA
ACA
PA
Ulcer Therapy
73
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
omeprazole
magnesium
1
omeprazole oral
capsule,delayed
release(dr/ec)
1
omeprazole oral
tablet,delayed
release (dr/ec)
1
OTC
3
ST
cimetidine
1
cimetidine hcl
1
CYTOTEC
3
DEXILANT
3
ST
esomeprazole
magnesium
1
PA; QL
esomeprazole
sodium
1
PA
ESOMEPRAZOLE
STRONTIUM
3
PA
OMEPRAZOLE+S
YRSPEND SF
ALKA
famotidine (pf)
1
PA
omeprazole-sodium
bicarbonate
1
PA
famotidine (pf)-nacl
(iso-os)
1
PA
pantoprazole
intravenous
1
PA
famotidine
intravenous
1
PA
pantoprazole oral
1
famotidine oral
1
PEPCID
3
FIRSTLANSOPRAZOLE
3
ST
PREVACID 24HR
1
OTC; QL
3
ST
FIRSTOMEPRAZOLE
3
ST
PREVACID
SOLUTAB
PREVPAC
3
heartburn treatment
24 hour
1
PRILOSEC
3
PRILOSEC OTC
1
OTC
HELIDAC
3
3
PA
lansoprazole oral
capsule,delayed
release(dr/ec) 15 mg
1
PROTONIX
INTRAVENOUS
PROTONIX ORAL
3
PA; ST
lansoprazole oral
capsule,delayed
release(dr/ec) 30 mg
1
PYLERA
2
rabeprazole
1
PA; QL
1
PA
misoprostol
1
ranitidine hcl
injection
NEXIUM 24HR
1
OTC
ranitidine hcl oral
1
NEXIUM PACKET
3
PA
sucralfate
1
nizatidine
1
3
OMECLAMOXPAK
3
ZANTAC
INJECTION
ZANTAC ORAL
3
ZEGERID
3
OTC; QL
QL
74
OTC
PA
ST
Drug Name
Tier
Restrictions /
Limits
Drug Name
OTC; QL
NUTROPIN AQ
3
PA; LA
Immunology, Vaccines &
Biotechnology
NUTROPIN AQ
NUSPIN
3
PA; LA
Biotechnology Drugs
OMNITROPE
3
PA; LA
SAIZEN
3
PA; LA
SAIZEN
CLICK.EASY
3
PA; LA
SEROSTIM
3
PA; LA
ZOMACTON
3
PA; LA
ZORBTIVE
3
PA; LA
ZEGERID OTC
1
QL
Tier
Restrictions /
Limits
ARANESP (IN
POLYSORBATE)
2
EPOGEN
3
QL
GRANIX
3
QL
LEUKINE
3
MIRCERA
3
MOZOBIL
3
PA; LA
Interferons
NEULASTA
3
QL
AUBAGIO
3
PA; LA; QL
NEUPOGEN
2
QL
AVONEX
2
PA; LA
PROCRIT
2
QL
AVONEX (WITH
ALBUMIN)
2
PA; LA; QL
ZARXIO
3
QL
BETASERON
2
PA; LA
PA; LA; QL
3
PA
GENOTROPIN
3
PA; LA
COPAXONE
SUBCUTANEOUS
SYRINGE 20
MG/ML
3
EGRIFTA
GENOTROPIN
MINIQUICK
3
PA; LA
2
PA; LA
HUMATROPE
3
PA; LA
NORDITROPIN
FLEXPRO
SUBCUTANEOUS
PEN INJECTOR 10
MG/1.5 ML (6.7
MG/ML), 15
MG/1.5 ML (10
MG/ML), 5 MG/1.5
ML (3.3 MG/ML)
2
PA; LA
COPAXONE
SUBCUTANEOUS
SYRINGE 40
MG/ML
COPEGUS
3
LA
EXTAVIA
SUBCUTANEOUS
KIT
3
PA; LA
EXTAVIA
SUBCUTANEOUS
RECON SOLN
3
LA
NORDITROPIN
FLEXPRO
SUBCUTANEOUS
PEN INJECTOR 30
MG/3 ML (10
MG/ML)
3
GILENYA
2
PA; LA
glatopa
1
PA; LA; QL
INFERGEN
3
PA; LA; QL
LEMTRADA
3
PA
moderiba
1
Growth Hormones
PA; LA
75
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
moderiba dose pack
1
PEGASYS
3
PA; LA
PEGASYS
PROCLICK
3
PA; LA
PEGINTRON
3
PA; LA; QL
PEGINTRON
REDIPEN
3
PA; LA
PLEGRIDY
2
PA; LA
POMALYST
3
PA; LA
REBETOL
3
LA
REBIF (WITH
ALBUMIN)
3
PA; LA
Vaccines & Miscellaneous
Immunologicals
REBIF REBIDOSE
3
PA; LA
ACTHIB (PF)
0
ACA
REBIF TITRATION
PACK
3
PA; LA
0
ACA
REVLIMID
3
PA; LA
ADACEL(TDAP
ADOLESN/ADULT
)(PF)
ribasphere
1
LA
AFLURIA 20122013
0
ACA
ribasphere ribapak
1
LA
0
ACA
ribavirin
1
LA
AFLURIA 20122013 (PF)
SYLATRON
3
PA; LA
0
ACA
TECFIDERA
2
PA; LA
AFLURIA 20132014
ZINBRYTA
3
PA; LA
0
ACA
AFLURIA 20142015
0
ACA
0
ACA
AFLURIA 20152016
0
ACA
Interleukins
ZYCLARA
TOPICAL CREAM
IN METEREDDOSE PUMP 2.5 %
3
ZYCLARA
TOPICAL CREAM
IN METEREDDOSE PUMP 3.75
%
3
QL
ZYCLARA
TOPICAL CREAM
IN PACKET
3
QL
ACTIMMUNE
2
PA; LA
ALDARA
3
QL
ALFERON N
2
PA; LA
ARCALYST
3
PA; LA
ILARIS (PF)
3
PA; LA
ACA
1
QL
0
imiquimod
INTRON A
2
PA; LA
ATGAM
3
PA; LA
KINERET
3
PA; QL
0
PA; ACA; LA
NEUMEGA
3
LA
BCG VACCINE,
LIVE (PF)
PROLEUKIN
3
PA; LA
BEXSERO (PF)
0
ACA
76
Drug Name
Tier
Restrictions /
Limits
Drug Name
BIVIGAM
Tier
Restrictions /
Limits
3
PA; LA
0
ACA
BOOSTRIX TDAP
0
ACA
FLUBLOK 20142015 (PF)
CARIMUNE NF
NANOFILTERED
3
PA; LA
0
ACA
CERVARIX
VACCINE (PF)
0
ACA
FLUCELVAX (PF)
0
ACA
0
ACA
COMVAX (PF)
0
ACA
FLUCELVAX
2013-2014 (PF)
DAPTACEL (DTAP
PEDIATRIC) (PF)
0
ACA
FLUCELVAX
2014-2015 (PF)
0
ACA
DYSPORT
3
PA; LA
FLUCELVAX
2015-2016 (PF)
0
ACA
ENGERIX-B (PF)
0
ACA
ACA
0
ACA
FLULAVAL 20122013
0
ENGERIX-B
PEDIATRIC (PF)
ACA
0
ACA
FLULAVAL 20132014
0
EZ FLU 2015-16
(FLUVIRIN) (PF)
ACA
0
ACA
FLULAVAL 20142015
0
EZ FLU 201516(FLUCELVAX)(P
F)
FLULAVAL QUAD
2013-2014
0
ACA
FLEBOGAMMA
DIF
3
PA; LA
FLULAVAL QUAD
2014-2015
0
ACA
FLUARIX 20122013 (PF)
0
ACA
FLULAVAL QUAD
2014-2015 (PF)
0
ACA
0
ACA
FLULAVAL QUAD
2015-2016
0
ACA
0
ACA
FLULAVAL QUAD
2016-2017
0
ACA
FLUARIX QUAD
2013-2014 (PF)
0
ACA
FLUMIST 20122013
0
ACA
FLUARIX QUAD
2014-2015 (PF)
0
ACA
FLUMIST 20132014
0
ACA
FLUARIX QUAD
2015-2016 (PF)
0
ACA
FLUMIST QUAD
2014-2015
0
ACA
FLUARIX QUAD
2016-2017 (PF)
0
ACA
FLUMIST QUAD
2015-2016
0
ACA
0
ACA
FLUVIRIN 20122013
0
ACA
77
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
FLUZONE
INTRADERM
2012-13 (PF)
0
ACA
FLUZONE
INTRADERM
2013-14 (PF)
0
ACA
FLUZONE
INTRADERM
2014-15 (PF)
0
ACA
FLUZONE
INTRADERM
QUAD 2015-16
0
ACA
FLUZONE
INTRADERM
QUAD 2016-17
0
ACA
FLUVIRIN 20122013 (PF)
0
ACA
FLUVIRIN 20132014
0
ACA
0
ACA
FLUVIRIN 20142015
0
ACA
0
ACA
FLUVIRIN 20152016
0
ACA
0
ACA
FLUZONE 20122013
0
ACA
FLUZONE PEDI
2012 -2013 (PF)
0
ACA
FLUZONE 20122013 (PF)
0
ACA
FLUZONE PEDI
2013-2014 (PF)
0
ACA
FLUZONE 20132014
0
ACA
FLUZONE QUAD
2013-2014 (PF)
0
ACA
0
ACA
FLUZONE QUAD
2014-2015
0
ACA
FLUZONE 20142015
0
ACA
FLUZONE QUAD
2014-2015 (PF)
0
ACA
0
ACA
FLUZONE QUAD
2015-2016
0
ACA
FLUZONE 20152016
0
ACA
FLUZONE QUAD
2015-2016 (PF)
0
ACA
FLUZONE HIGHDOSE 2012-13 (PF)
0
ACA
FLUZONE QUAD
2016-2017
0
ACA
0
ACA
FLUZONE QUAD
2016-2017 (PF)
0
ACA
0
ACA
FLUZONE QUAD
PEDI 2013-14 (PF)
0
ACA
0
ACA
FLUZONE QUAD
PEDI 2014-15 (PF)
0
ACA
0
ACA
FLUZONE QUAD
PEDI 2015-16 (PF)
0
ACA
78
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
ORALAIR
3
PA; LA
PEDIARIX (PF)
0
ACA
PEDVAX HIB (PF)
0
ACA
PENTACEL (PF)
0
ACA
0
ACA
FLUZONE QUAD
PEDI 2016-17 (PF)
0
ACA
GARDASIL (PF)
0
ACA
GARDASIL 9 (PF)
0
ACA
GRASTEK
3
PA
HAVRIX (PF)
0
ACA
PHYSICIANS EZ
USE FLU 2012-13
HEPAGAM B
3
PA; LA
PNEUMOVAX 23
0
ACA
HIZENTRA
3
PA
PREVNAR 13 (PF)
0
ACA
HYPERHEP B S/D
INTRAMUSCULA
R SOLUTION
2
PA; LA
PROQUAD (PF)
0
ACA
QUADRACEL (PF)
0
ACA
HYPERHEP B S/D
INTRAMUSCULA
R SYRINGE
3
RAGWITEK
3
PA
RECOMBIVAX HB
(PF)
0
ACA
HYPERHEP B S-D
NEONATAL
3
PA; LA
ROTARIX
0
ACA
ACA
3
LA
ROTATEQ
VACCINE
0
HYPERRAB S/D
(PF)
0
ACA
IMOGAM RABIESHT (PF)
3
SINGLE USE EZ
FLU 2012-13 (PF)
ACA
0
ACA
SINGLE USE EZ
FLU 2013-14 (PF)
0
INFANRIX (DTAP)
(PF)
0
ACA
IPOL
0
ACA
SINGLE USE EZ
FLU 2014-15(PF)
KINRIX (PF)
0
ACA
TENIVAC (PF)
0
ACA
MENACTRA (PF)
0
ACA
0
ACA
MENHIBRIX (PF)
0
ACA
tetanus
toxoid,adsorbed (pf)
MENOMUNE A/C/Y/W-135
0
ACA
TETANUS,DIPHTH
ERIA TOX
PED(PF)
0
ACA
MENOMUNE A/C/Y/W-135 (PF)
0
ACA
0
ACA
MENVEO A-C-YW-135-DIP (PF)
0
ACA
TETANUSDIPHTHERIA
TOXOIDS-TD
3
PA; LA
M-M-R II (PF)
0
ACA
THYMOGLOBULI
N
MYOBLOC
3
PA; LA
TRUMENBA
0
ACA
NABI-HB
3
PA; LA
TWINRIX (PF)
0
ACA
PA; LA
79
Drug Name
Tier
Restrictions /
Limits
Drug Name
VAQTA (PF)
0
ACA
EVISTA
3
VARIVAX (PF)
0
ACA
FORTEO
2
VARIZIG
0
PA; ACA
FOSAMAX
3
QL
ZOSTAVAX (PF)
0
ACA
FOSAMAX PLUS
D ORAL TABLET
70 MG- 2,800 UNIT
3
QL
FOSAMAX PLUS
D ORAL TABLET
70 MG- 5,600 UNIT
3
Musculoskeletal & Rheumatology
Gout Therapy
Tier
Restrictions /
Limits
allopurinol
1
aloprim
1
COLCHICINE
3
ibandronate
intravenous
1
PA; LA
colchicineprobenecid
1
ibandronate oral
1
QL
COLCRYS
2
PROLIA
3
PA; LA; QL
KRYSTEXXA
3
raloxifene
0
ACA
MITIGARE
3
risedronate oral
tablet 150 mg, 5 mg
1
probenecid
1
1
QL
ULORIC
3
risedronate oral
tablet 35 mg
ZYLOPRIM
3
risedronate oral
tablet,delayed
release (dr/ec)
1
ST
PA
PA; LA
Osteoporosis Therapy
ACTONEL ORAL
TABLET 150 MG, 5
MG
3
ACTONEL ORAL
TABLET 35 MG
3
alendronate oral
solution
Other Rheumatologicals
ACTEMRA
3
ARAVA
3
BENLYSTA
3
1
CUPRIMINE
2
alendronate oral
tablet 10 mg, 5 mg
1
DEPEN
TITRATABS
3
alendronate oral
tablet 35 mg, 70 mg
1
ENBREL
2
PA; LA; QL
2
PA; LA; QL
ATELVIA
3
ENBREL
SURECLICK
BINOSTO
3
HUMIRA
2
PA; LA; QL
BONIVA
INTRAVENOUS
3
PA; LA
HUMIRA
PEDIATRIC
CROHN'S START
2
PA; LA; QL
BONIVA ORAL
3
ST; QL
QL
QL
80
PA; LA
PA; LA
Drug Name
Tier
Restrictions /
Limits
Drug Name
PA; LA; QL
Estrogens & Progestins
HUMIRA PEN
CROHN'S-UC-HS
START
2
leflunomide
1
ORENCIA
2
ORENCIA (WITH
MALTOSE)
2
ORENCIA
CLICKJECT
2
PA; LA
OTEZLA
3
PA; LA
OTEZLA
STARTER
3
PA; LA
OTREXUP (PF)
3
RASUVO (PF)
3
RIDAURA
Tier
Restrictions /
Limits
ACTIVELLA
3
ALORA
3
PA; LA
ANGELIQ
3
PA; LA
AYGESTIN
3
camila
0
CENESTIN
3
CLIMARA
3
CLIMARA PRO
3
COMBIPATCH
2
PA
covaryx
1
PA
covaryx h.s.
1
2
CRINONE
3
SAVELLA
2
deblitane
0
SIMPONI
3
PA; LA; QL
DELESTROGEN
3
SIMPONI ARIA
3
PA; LA; QL
DEPO-ESTRADIOL
3
XELJANZ
3
PA; LA; QL
3
XELJANZ XR
3
PA; LA
DEPO-PROVERA
INTRAMUSCULA
R SOLUTION
DEPO-PROVERA
INTRAMUSCULA
R SUSPENSION
0
ACA; QL
DEPO-PROVERA
INTRAMUSCULA
R SYRINGE
0
ACA; QL
Obstetrics & Gynecology
Diaphragms And Other Non-Oral
Contraceptives
ACA; QL
ACA; QL
PA
CAYA
CONTOURED
0
ACA; QL
FC2 FEMALE
CONDOM
0
ACA; OTC
DEPO-SUBQ
PROVERA 104
0
ACA; QL
FEMCAP
0
ACA
DIVIGEL
3
QL
LILETTA
0
ACA; LA
DUAVEE
2
MIRENA
0
ACA
eemt
1
PARAGARD T
380A
0
ACA
eemt hs
1
ELESTRIN
3
QL
SKYLA
0
ACA
ENDOMETRIN
3
PA
ENJUVIA
3
WIDE-SEAL
0
ACA
DIAPHRAGM
81
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
ACA; QL
jencycla
0
Restrictions /
Limits
errin
0
ESTRACE ORAL
3
jevantique lo
1
ESTRACE
VAGINAL
2
jinteli
1
jolivette
0
estradiol
1
lopreeza
1
estradiol valerate
1
lyza
0
estradiolnorethindrone acet
1
MAKENA
2
ESTRING
2
medroxyprogesteron
e intramuscular
0
ESTROGEL
3
1
medroxyprogesteron
e oral
1
estrogensmethyltestosterone
MENEST
3
estropipate
1
MENOSTAR
3
EVAMIST
2
mimvey
1
FEMHRT LOW
DOSE
3
mimvey lo
1
FEMRING
3
QL
MINIVELLE
3
FIRSTPROGESTERONE
VGS 100
3
PA
nora-be
0
ACA; QL
norethindrone
(contraceptive)
0
ACA; QL
FIRSTPROGESTERONE
VGS 200
3
norethindrone
acetate
1
1
FIRSTPROGESTERONE
VGS 25
3
norethindrone ac-eth
estradiol
norlyroc
0
ACA; QL
FIRSTPROGESTERONE
VGS 400
3
NOR-QD
0
ACA; QL
ORTHO
MICRONOR
0
ACA; QL
FIRSTPROGESTERONE
VGS 50
3
PREFEST
3
PREMARIN
INJECTION
3
fyavolv
1
PREMARIN ORAL
2
heather
0
2
hydroxyprogesterone
caproate
1
PREMARIN
VAGINAL
PREMPHASE
2
QL
PA
PA
PA
PA
ACA; QL
82
ACA; QL
ACA; QL
ACA; QL
ACA; QL
PA
Drug Name
Tier
PREMPRO
Restrictions /
Limits
Drug Name
Tier
2
NUVARING
0
progesterone
1
NUVESSA
3
progesterone
micronized
1
OSPHENA
3
PREPIDIL
3
PROMETRIUM
3
PROSTIN E2
3
PROVERA
3
RELAGARD
3
sharobel
0
TERAZOL 3
3
VAGIFEM
2
TERAZOL 7
3
VIVELLE-DOT
3
terconazole
1
TODAY
CONTRACEPTIVE
SPONGE
0
tranexamic acid
1
vaginal
contraceptive foam
0
vandazole
1
VCF
CONTRACEPTIVE
FILM
0
ACA; OTC
VCF
CONTRACEPTIVE
GEL
0
ACA; OTC
0
ACA; QL
ACA; QL
Miscellaneous Ob/Gyn
Restrictions /
Limits
ACA; QL
ACA; OTC
AVC VAGINAL
3
CERVIDIL
3
CLEOCIN
VAGINAL CREAM
3
CLEOCIN
VAGINAL
SUPPOSITORY
2
clindamycin
phosphate
1
CLINDESSE
3
CONCEPTROL
0
fem ph
1
xulane
GYNAZOLE-1
3
isoxsuprine
1
Oral Contraceptives & Related
Agents
LUPANETA PACK
(1 MONTH)
3
AFTERA
0
ACA; OTC;
QL
LUPANETA PACK
(3 MONTH)
3
altavera (28)
0
ACA; QL
LYSTEDA
3
alyacen 1/35 (28)
0
ACA; QL
METROGEL
VAGINAL
3
alyacen 7/7/7 (28)
0
ACA; QL
amethia
0
ACA; QL
metronidazole
1
amethia lo
0
ACA; QL
miconazole-3
1
amethyst
0
ACA; QL
NEXPLANON
0
apri
0
ACA; QL
ACA; OTC
ACA
ACA; OTC
83
Drug Name
Tier
Restrictions /
Limits
Drug Name
aranelle (28)
0
ACA; QL
0
ACA; QL
ashlyna
0
ACA; QL
drospirenone-ethinyl
estradiol
aubra
0
ACA; QL
econtra ez
0
ACA; OTC;
QL
aviane
0
ACA; QL
elinest
0
ACA; QL
azurette (28)
0
ACA; QL
ELLA
0
ACA; QL
balziva (28)
0
ACA; QL
emoquette
0
ACA; QL
bekyree (28)
0
ACA; QL
enpresse
0
ACA; QL
BEYAZ
0
ACA; QL
enskyce
0
ACA
blisovi 24 fe
0
ACA; QL
estarylla
0
ACA; QL
blisovi fe 1.5/30 (28)
0
ACA; QL
ESTROSTEP FE-28
0
ACA; QL
blisovi fe 1/20 (28)
0
ACA; QL
fallback solo
0
BREVICON (28)
0
ACA; QL
ACA; OTC;
QL
briellyn
0
ACA; QL
falmina (28)
0
ACA; QL
camrese
0
ACA; QL
FEMCON FE
0
ACA; QL
camrese lo
0
ACA; QL
GENERESS FE
0
ACA; QL
caziant (28)
0
ACA; QL
gianvi (28)
0
ACA; QL
chateal
0
ACA; QL
gildagia
0
ACA; QL
cryselle (28)
0
ACA; QL
gildess 1.5/30 (21)
0
ACA; QL
cyclafem 1/35 (28)
0
ACA; QL
gildess 1/20 (21)
0
ACA; QL
cyclafem 7/7/7 (28)
0
ACA; QL
gildess 24 fe
0
ACA; QL
CYCLESSA (28)
0
ACA; QL
gildess fe 1.5/30 (28)
0
ACA; QL
cyred
0
ACA; QL
gildess fe 1/20 (28)
0
ACA; QL
dasetta 1/35 (28)
0
ACA; QL
introvale
0
ACA; QL
dasetta 7/7/7 (28)
0
ACA; QL
jolessa
0
ACA; QL
daysee
0
ACA; QL
juleber
0
ACA; QL
delyla (28)
0
ACA; QL
junel 1.5/30 (21)
0
ACA; QL
desoge.estradiol/e.estradio
l
0
ACA; QL
junel 1/20 (21)
0
ACA; QL
junel fe 1.5/30 (28)
0
ACA; QL
DESOGEN
0
ACA; QL
junel fe 1/20 (28)
0
ACA; QL
desogestrel-ethinyl
estradiol
0
ACA; QL
junel fe 24
0
ACA; QL
kaitlib fe
0
ACA; QL
kariva (28)
0
ACA; QL
84
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
kelnor 1/35 (28)
0
ACA; QL
lutera (28)
0
ACA; QL
kimidess (28)
0
ACA; QL
marlissa
0
ACA; QL
kurvelo
0
ACA; QL
0
ACA; QL
l norgest/e.estradiole.estrad
0
ACA; QL
microgestin 1.5/30
(21)
0
ACA; QL
larin 1.5/30 (21)
0
ACA; QL
microgestin 1/20
(21)
larin 1/20 (21)
0
ACA; QL
MICROGESTIN 24
FE
0
ACA; QL
larin 24 fe
0
ACA; QL
ACA; QL
0
ACA; QL
microgestin fe 1.5/30
(28)
0
larin fe 1.5/30 (28)
larin fe 1/20 (28)
0
ACA; QL
0
ACA; QL
layolis fe
0
ACA; QL
microgestin fe 1/20
(28)
leena 28
0
ACA; QL
MINASTRIN 24 FE
0
ACA; QL
lessina
0
ACA; QL
MIRCETTE (28)
0
ACA; QL
levonest (28)
0
ACA; QL
MODICON (28)
0
ACA; QL
levonorgestrelethinyl estrad
0
ACA; QL
mono-linyah
0
ACA; QL
mononessa (28)
0
ACA; QL
levonorg-eth estrad
triphasic
0
ACA; QL
my way
0
ACA; OTC;
QL
levora-28
0
ACA; QL
myzilra
0
ACA; QL
LO LOESTRIN FE
0
ACA; QL
NATAZIA
0
ACA; QL
LO MINASTRIN
FE
0
ACA; QL
necon 0.5/35 (28)
0
ACA; QL
necon 1/35 (28)
0
ACA; QL
LOESTRIN 1.5/30
(21)
0
ACA; QL
necon 1/50 (28)
0
ACA; QL
LOESTRIN 1/20
(21)
0
ACA; QL
necon 10/11 (28)
0
ACA; QL
necon 7/7/7 (28)
0
ACA; QL
LOESTRIN FE
1.5/30 (28-DAY)
0
ACA; QL
next choice one dose
0
ACA; OTC;
QL
LOESTRIN FE 1/20
(28-DAY)
0
ACA; QL
nikki (28)
0
ACA; QL
ACA; QL
0
ACA; QL
noreth-ethinyl
estradiol-iron
0
lomedia 24 fe
loryna (28)
0
ACA; QL
0
ACA; QL
LOSEASONIQUE
0
ACA; QL
norethindrone ac-eth
estradiol
low-ogestrel (28)
0
ACA; QL
norethindronee.estradiol-iron
0
ACA; QL
85
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
norgestimate-ethinyl
estradiol
0
ACA; QL
react
0
ACA; OTC;
QL
NORINYL 1+35
(28)
0
ACA; QL
reclipsen (28)
0
ACA; QL
SAFYRAL
0
ACA; QL
NORINYL 1+50
(28)
0
ACA; QL
SEASONIQUE
0
ACA; QL
nortrel 0.5/35 (28)
0
ACA; QL
setlakin
0
ACA; QL
nortrel 1/35 (21)
0
ACA; QL
sprintec (28)
0
ACA; QL
nortrel 7/7/7 (28)
0
ACA; QL
sronyx
0
ACA; QL
ocella
0
ACA; QL
syeda
0
ACA; QL
ogestrel (28)
0
ACA; QL
TAKE ACTION
0
ACA; OTC;
QL
opcicon one-step
0
ACA; OTC;
QL
tarina fe 1/20 (28)
0
ACA; QL
orsythia
0
ACA; QL
tilia fe
0
ACA; QL
ORTHO TRICYCLEN (28)
0
ACA; QL
tri-estarylla
0
ACA; QL
tri-legest fe
0
ACA; QL
ORTHO TRICYCLEN LO (28)
0
ACA; QL
tri-linyah
0
ACA; QL
tri-lo-estarylla
0
ACA; QL
ORTHO-CYCLEN
(28)
0
ACA; QL
tri-lo-marzia
0
ACA; QL
ORTHO-NOVUM
1/35 (28)
0
ACA; QL
tri-lo-sprintec
0
ACA; QL
trinessa (28)
0
ACA; QL
ORTHO-NOVUM
7/7/7 (28)
0
trinessa lo
0
ACA; QL
TRI-NORINYL (28)
0
ACA; QL
OVCON-35 (28)
0
ACA; QL
tri-previfem (28)
0
ACA; QL
philith
0
ACA; QL
tri-sprintec (28)
0
ACA; QL
pimtrea (28)
0
ACA; QL
trivora (28)
0
ACA; QL
pirmella
0
ACA; QL
0
ACA; QL
PLAN B ONESTEP
0
ACA; QL
velivet triphasic
regimen (28)
vestura (28)
0
ACA; QL
portia
0
ACA; QL
vienva
0
ACA; QL
previfem
0
ACA; QL
viorele (28)
0
ACA; QL
QUARTETTE
0
ACA; QL
vyfemla (28)
0
ACA; QL
quasense
0
ACA; QL
wera (28)
0
ACA; QL
wymzya fe
0
ACA; QL
ACA; QL
86
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
neomycinbacitracinpolymyxin
1
1
YASMIN (28)
0
ACA; QL
YAZ (28)
0
ACA; QL
zarah
0
ACA; QL
zenchent (28)
0
ACA; QL
zenchent fe
0
ACA; QL
neomycinpolymyxingramicidin
zovia 1/35e (28)
0
ACA; QL
neo-polycin
1
zovia 1/50e (28)
0
ACA; QL
NEOSPORIN
(NEO-POLYMGRAMICID)
3
Oxytocics
methergine
1
OCUFLOX
3
methylergonovine
1
ofloxacin
1
Ophthalmology
polycin
1
Antibiotics
polycin b
1
polymyxin b sulftrimethoprim
1
POLYTRIM
3
romycin
1
tobramycin
1
ALODOX
3
AZASITE
3
bacitracin
1
bacitracinpolymyxin b
1
BESIVANCE
3
TOBREX
3
BETADINE
OPHTHALMIC
PREP
3
VIGAMOX
3
ZYMAXID
3
CILOXAN
3
ciprofloxacin hcl
1
erythromycin
1
gatifloxacin
1
gentak
1
gentamicin
1
ILOTYCIN
3
levofloxacin
1
MOXEZA
3
NATACYN
3
Restrictions /
Limits
Antivirals
trifluridine
1
VIROPTIC
3
ZIRGAN
3
Beta-Blockers
BETAGAN
3
betaxolol
1
BETIMOL
3
BETOPTIC S
3
carteolol
1
ISTALOL
3
levobunolol
1
87
Drug Name
Tier
metipranolol
Restrictions /
Limits
Drug Name
Tier
1
AKTEN (PF)
3
timolol maleate
1
ALCAINE
3
TIMOPTIC
3
ALOCRIL
2
TIMOPTIC
OCUDOSE (PF)
2
ALOMIDE
2
altacaine
1
TIMOPTIC-XE
3
altafluor
1
Cholinesterase Inhibitor Miotics
AVENOVA
3
PHOSPHOLINE
IODIDE
azelastine
1
BEPREVE
3
cromolyn
1
CYSTARAN
3
ELESTAT
3
EMADINE
3
epinastine
1
EYLEA
3
flucaine
1
fluoresceinbenoxinate
1
fluoresceinproparacaine
1
flurox
1
JETREA (PF)
3
LACRISERT
3
LASTACAFT
3
LUCENTIS
3
PA
MACUGEN
3
PA; LA
2
Cycloplegic Mydriatics
atropine
1
CYCLOGYL
OPHTHALMIC
DROPS 0.5 %, 1 %
2
CYCLOGYL
OPHTHALMIC
DROPS 2 %
3
cyclopentolate
1
homatropaire
1
homatropine hbr
1
ISOPTO
ATROPINE
3
mydral
1
MYDRIACYL
3
PAREMYD
3
tropicamide
1
Direct Acting Miotics
ISOPTO CARPINE
3
olopatadine
1
MIOCHOL-E
3
OMIDRIA
3
pilocarpine hcl
1
parcaine
1
PILOPINE HS
2
PATADAY
3
Miscellaneous Ophthalmologics
PATANOL
2
acuicyn
PAZEO
3
1
88
Restrictions /
Limits
PA; LA
PA
Drug Name
Tier
proparacaine
1
RESTASIS
2
tetcaine
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
AZOPT
3
COMBIGAN
3
1
COSOPT
3
tetracaine hcl
1
COSOPT (PF)
3
tetracaine hcl (pf)
1
dorzolamide
1
TETRAVISC
3
dorzolamide-timolol
1
TETRAVISC
FORTE
3
latanoprost
1
LUMIGAN
2
ST
VISUDYNE
3
PA; LA
miostat
1
PA
VITRASE
3
PA
MITOSOL
3
RESCULA
3
SIMBRINZA
3
TRAVATAN Z
3
QL
Non-Steroidal Anti-Inflammatory
Agents
ACULAR
3
ACULAR LS
3
3
travoprost
(benzalkonium)
1
ACUVAIL (PF)
bromfenac
1
TRUSOPT
3
diclofenac sodium
1
XALATAN
3
flurbiprofen sodium
1
ZIOPTAN (PF)
3
ILEVRO
3
Steroid-Antibiotic Combinations
ketorolac
1
MAXITROL
3
NEVANAC
3
1
OCUFEN
3
neomycinbacitracin-poly-hc
PROLENSA
3
neomycin-polymyxin
b-dexameth
1
neomycinpolymyxin-hc
1
neo-polycin hc
1
poly-dex
1
PRED-G
2
Oral Drugs For Glaucoma
acetazolamide
1
acetazolamide
sodium
1
DIAMOX
SEQUELS
3
methazolamide
1
PRED-G S.O.P.
2
NEPTAZANE
3
TOBRADEX
3
TOBRADEX ST
3
PA
Other Glaucoma Drugs
ST
ST
89
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
1
tobramycindexamethasone
1
sulfacetamide
sodium
ZYLET
2
Sympathomimetics
Steroids
QL
ALPHAGAN P
OPHTHALMIC
DROPS 0.1 %
2
3
Restrictions /
Limits
ALREX
3
dexamethasone
sodium phosphate
1
DUREZOL
3
ALPHAGAN P
OPHTHALMIC
DROPS 0.15 %
FLAREX
3
apraclonidine
1
fluorometholone
1
brimonidine
1
FML FORTE
3
IOPIDINE
3
FML LIQUIFILM
3
Vasoconstrictor Decongestants
FML S.O.P.
3
CYCLOMYDRIL
3
ILUVIEN
3
naphazoline
1
LOTEMAX
3
phenylephrine hcl
1
MAXIDEX
3
Respiratory, Allergy, Cough & Cold
OMNIPRED
3
PRED FORTE
3
Antihistamine & Antiallergenic
Agents
PRED MILD
2
ADRENACLICK
3
QL
prednisolone acetate
1
adrenalin
1
PA
prednisolone sodium
phosphate
1
arbinoxa
1
RETISERT
3
carbinoxamine
maleate
1
VEXOL
2
CLARINEX ORAL
SYRUP
3
PA
CLARINEX ORAL
TABLET
3
PA; QL
clemastine
1
cyproheptadine
1
desloratadine
1
diphenhydramine hcl
1
doxytex
1
dytuss
1
LA
Steroid-Sulfonamide Combinations
BLEPHAMIDE
2
BLEPHAMIDE
S.O.P.
2
sulfacetamideprednisolone
1
Sulfonamides
BLEPH-10
3
90
PA; QL
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
QL
AMBIFED DM
3
benzonatate
1
BROMFED DM
3
brompheniraminepseudoeph-dm
1
CAPCOF
3
centergy
1
cheratussin ac
1
PA
cheratussin dac
1
3
epinephrine
injection autoinjector 0.15
mg/0.15 ml
1
epinephrine
injection autoinjector 0.3 mg/0.3
ml
1
epinephrine
injection solution
1
epinephrine
injection syringe
1
EPIPEN 2-PAK
2
QL
CLARINEX-D 12
HOUR
EPIPEN JR 2-PAK
2
QL
CODAR AR
3
EPISNAP
3
CODAR D
3
hydroxyzine hcl
intramuscular
1
codeine-guaifenesin
1
FLOWTUSS
3
hydroxyzine hcl oral
1
GENTEX 30
3
hydroxyzine
pamoate
1
guaifenesin ac
1
KARBINAL ER
3
guaifenesin dac
1
levocetirizine
1
HISTEX-AC
3
phenadoz
1
HYCOFENIX
3
PHENERGAN
INJECTION
3
hydrocodonechlorpheniramine
1
phenergan rectal
1
hydrocodone-cpmpseudoephed
1
promethazine
1
1
promethegan
1
hydrocodonehomatropine
VISTARIL
3
hydromet
1
XYZAL
3
indamix dm
1
Cough & Cold Therapy
iophen c-nr
1
ALLFEN CDX
3
lortuss ex
1
ambi 10peh-400gfn20dm
1
MAR-COF BP
3
MAR-COF CG
3
AMBIFED
3
MAXIFED (IR)
3
PA; QL
PA
PA
Restrictions /
Limits
PA; QL
PA
PA
91
Drug Name
Tier
Restrictions /
Limits
m-clear wc
1
TRICODE AR
3
M-END MAX D
3
TRICODE GF
3
M-END PE
3
tusnel c
1
NEOTUSS-D
(CHLORPHENIRA
MINE)
3
TUSNEL
PEDIATRIC
3
TUSSICAPS
3
NINJACOF-XG
3
tussigon
1
OBREDON
3
1
TUSSIONEX
PENNKINETIC ER
3
pe-guai
phenylhistine dh
1
TUZISTRA XR
3
POLY HIST NC
3
VANACOF CD
3
POLY-TUSSIN AC
3
virtussin ac
1
poly-tussin d
1
virtussin dac
1
PRO-CLEAR CAPS
3
VITUZ
3
promethazine vc
1
ZODRYL AC 25
3
promethazine vccodeine
1
ZODRYL AC 30
3
ZODRYL AC 35
3
promethazinecodeine
1
ZODRYL AC 40
3
promethazine-dm
1
ZODRYL AC 50
3
promethazinephenyleph-codeine
1
ZODRYL AC 60
3
ZODRYL AC 80
3
PRO-RED AC (W/
DEXCHLORPHENI
R)
3
ZODRYL DAC 25
3
ZODRYL DAC 30
3
relcof c
1
ZODRYL DAC 35
3
RESPA-AR
3
ZODRYL DAC 40
3
REZIRA
3
ZODRYL DAC 50
3
r-tanna
1
ZODRYL DAC 60
3
ru-hist forte
1
ZODRYL DAC 80
3
rydex
1
ZODRYL DEC 25
3
SEMPREX-D
3
ZODRYL DEC 30
2
TESSALON
PERLES
3
ZODRYL DEC 35
3
ZODRYL DEC 40
3
92
Drug Name
Tier
Restrictions /
Limits
PA
PA
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
ZODRYL DEC 50
3
budesonide nasal
1
ZODRYL DEC 60
3
2
ST; OTC
ZODRYL DEC 80
3
CHILDREN'S
NASACORT
ZONATUSS
3
CINQAIR
3
PA; LA
Z-TUSS AC
3
CINRYZE
3
PA; LA
ZUTRIPRO
3
COMBIVENT
RESPIMAT
2
cromolyn
1
Pulmonary Agents
ACCOLATE
3
CUROSURF
3
acetylcysteine
1
DALIRESP
3
ADCIRCA
3
PA; LA
difil-g 400
1
ADEMPAS
3
PA; LA
DULERA
2
ADVAIR DISKUS
2
QL
DYMISTA
3
ADVAIR HFA
2
QL
ELIXOPHYLLIN
3
AEROSPAN
3
ESBRIET
3
PA; LA
albuterol sulfate
1
FIRAZYR
3
PA; LA; QL
ALVESCO
3
FLOVENT DISKUS
2
QL
ANORO ELLIPTA
2
FLOVENT HFA
2
QL
ARCAPTA
NEOHALER
3
flunisolide
1
ARNUITY
ELLIPTA
3
fluticasone
1
3
ASMANEX HFA
3
QL
FORADIL
AEROLIZER
ASMANEX
TWISTHALER
3
QL
HYPER-SAL
3
3
ATROVENT HFA
2
INCRUSE
ELLIPTA
BECONASE AQ
3
ST
ipratropium bromide
1
BERINERT
3
PA; LA
ipratropiumalbuterol
1
BEVESPI
AEROSPHERE
3
KALBITOR
3
PA; LA
BREO ELLIPTA
2
KALYDECO
3
PA; LA; QL
BROVANA
3
LETAIRIS
2
PA; LA; QL
budesonide
inhalation
1
levalbuterol hcl
1
LUFYLLIN
3
QL
QL
ST
93
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
MAXAIR
AUTOHALER
3
RUCONEST
3
1
SEEBRI
NEOHALER
3
metaproterenol
mometasone
1
2
montelukast
1
SEREVENT
DISKUS
NASACORT
2
ST; OTC
sildenafil
intravenous
1
PA; QL
nasal allergy
1
OTC
sildenafil oral
1
PA; LA; QL
NASONEX
3
SINGULAIR
3
NEBUSAL
3
sodium chloride
1
OFEV
3
PA; LA
3
ST
SPIRIVA
RESPIMAT
2
OMNARIS
OPSUMIT
3
PA; LA
2
ORKAMBI
3
PA; LA
SPIRIVA WITH
HANDIHALER
PERFOROMIST
3
STIOLTO
RESPIMAT
3
PROAIR HFA
2
2
STRIVERDI
RESPIMAT
3
PROAIR
RESPICLICK
SURFAXIN
3
PROVENTIL HFA
3
SYMBICORT
2
PULMICORT
3
terbutaline
1
PULMICORT
FLEXHALER
2
THEO-24
3
pulmosal
1
theochron
1
PULMOZYME
2
theophylline
1
QNASL
3
TRACLEER
3
QVAR
2
triamcinolone
acetonide
1
REVATIO
INTRAVENOUS
3
PA; LA; QL
TUDORZA
PRESSAIR
2
REVATIO ORAL
SUSPENSION FOR
RECONSTITUTIO
N
3
PA; LA
TYVASO
3
TYVASO REFILL
KIT
3
REVATIO ORAL
TABLET
3
PA; LA; QL
TYVASO
STARTER KIT
3
RHINOCORT
AQUA
3
ST
QL
ST
94
PA; LA
ST; LA; QL
LA; QL
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
UTIBRON
NEOHALER
3
VENTAVIS
3
alfuzosin
1
VENTOLIN HFA
2
AVODART
3
QL
VERAMYST
2
dutasteride
1
QL
VOSPIRE ER
3
1
XOLAIR
3
dutasteridetamsulosin
XOPENEX
3
finasteride
1
QL
XOPENEX
CONCENTRATE
3
FLOMAX
3
QL
JALYN
3
XOPENEX HFA
3
PROSCAR
3
QL
zafirlukast
1
RAPAFLO
2
ST
ZETONNA
3
tamsulosin
1
QL
ZYFLO
3
UROXATRAL
3
ZYFLO CR
3
Benign Prostatic Hyperplasia (Bph)
Therapy
PA; LA
PA; LA
ST
PA
Cholinergic Stimulants
Urologicals
bethanechol chloride
1
Anticholinergics & Antispasmodics
URECHOLINE
3
darifenacin
1
Miscellaneous Urologicals
DETROL
3
alprostadil
1
PA
DETROL LA
3
3
PA
DITROPAN XL
3
AMMONIUM
CHLORIDE
ENABLEX
3
azuphen mb
1
flavoxate
1
CYSTAGON
3
GELNIQUE
3
ST
cytra k crystals
1
MYRBETRIQ
2
ST
cytra-2
1
oxybutynin chloride
1
cytra-3
1
OXYTROL
3
cytra-k
1
tolterodine
1
ELMIRON
3
TOVIAZ
3
ST
hyolev mb
1
trospium
1
ST
hyophen
1
VESICARE
2
ST
INDIOMIN MB
3
K-PHOS NO 2
3
ST
ST
PA
95
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
K-PHOS
ORIGINAL
3
methen-sod phosmeth blue-hyos
1
ORACIT
3
phosphasal
1
pot,sodium citratecitric acid
1
potassium citrate
1
potassium citratecitric acid
1
PROCYSBI
3
PROSTIN VR
PEDIATRIC
3
RENACIDIN
3
SHOHL'S
MODIFIED
3
sodium citrate-citric
acid
1
tricitrates
1
Electrolytes
ur n-c
1
calcium 500 with d
0
ACA; OTC
uramit mb
1
0
ACA; OTC
URELLE
3
calcium carb and
citrate-vitd3
uretron d-s
1
calcium citrate + d
0
ACA; OTC
URIBEL
3
calcium citratevitamin d2
0
ACA; OTC
urimar-t
1
1
uro-blue
1
EFFER-K ORAL
TABLET,
EFFERVESCENT
10 MEQ, 20 MEQ
3
urin ds
UROCIT-K 10
3
1
UROCIT-K 15
3
effer-k oral tablet,
effervescent 25 meq
UROCIT-K 5
3
GALZIN
3
urogesic-blue
1
GLYCOPHOS
3
uro-l
1
k-effervescent
1
urolet mb
1
klor-con
1
uro-mp
1
urophen mb
1
UROQID-ACID
NO.2
3
uryl
1
ustell
1
UTA
3
utira-c
1
virtrate-2
1
virtrate-3
1
PA; LA
virtrate-k
1
PA
Urinary Anesthetics
96
phenazopyridine
1
phenazopyridine
plus
1
PYRIDIUM
3
Restrictions /
Limits
Vitamins, Hematinics & Electrolytes
PA
Drug Name
Tier
Restrictions /
Limits
klor-con 10
1
klor-con 8
1
klor-con m10
1
klor-con m15
1
klor-con m20
1
klor-con sprinkle
1
KLOR-CON/25
2
klor-con/ef
1
k-phos-neutral
1
k-sol
1
K-TAB ORAL
TABLET
EXTENDED
RELEASE 10 MEQ,
20 MEQ
3
k-tab oral tablet
extended release 8
meq
1
lugols
1
MICRO-K
3
NORMOSOL-R
3
phospha 250 neutral
1
POTABA
3
PA
potassium acetate
1
PA
potassium bicarb
and chloride
1
potassium bicarbcitric acid
1
potassium chloridd5-0.45%nacl
1
potassium chloride
in 0.9%nacl
potassium chloride
in 5 % dex
Drug Name
Tier
Restrictions /
Limits
potassium chloride
in lr-d5
1
PA
potassium chloride
intravenous
piggyback 10
meq/100 ml, 20
meq/100 ml, 30
meq/100 ml, 40
meq/100 ml
1
PA
potassium chloride
intravenous
piggyback 10
meq/50 ml, 20
meq/50 ml
1
potassium chloride
1
potassium chloride
oral
1
potassium chloride0.45 % nacl
1
PA
potassium chlorided5-0.2%nacl
intravenous
parenteral solution
10 meq/l, 20 meq/l,
40 meq/l
1
PA
intravenous
parenteral solution
30 meq/l
1
1
PA
PA
1
PA
1
PA
potassium phosphate
m-/d-basic
1
PA
1
PA
sodium chloride
1
sodium chloride 0.45
%
1
PA
PA
97
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
sodium chloride 3 %
1
BIFERA RX
3
sodium chloride 5 %
1
CADEAU DHA
3
sodium phosphate
1
calcium pnv
1
strong iodine
1
1
virt-phos 250 neutral
1
calcium-folic acidvitamin d
CARDIOTEK-RX
(BIOPERINE)
3
centratex
1
PA
Miscellaneous Vitamins, Hematinics,
& Electrolytes
FORTAVIT
3
3
PA
chewable multivita,b,d,e,k,zn
1
ISOLYTE S PH 7.4
ISOLYTE-S
3
PA
choice-tabs
1
NORMOSOL-R PH
7.4
3
PA
ciferex
1
3
PA
CITRANATAL
(DUAL-IRON)
3
PLASMA-LYTE
148
3
PA
CITRANATAL 90
DHA (ALGAL OIL)
3
PLASMA-LYTE A
CITRANATAL
ASSURE
3
CITRANATAL BCALM (FE GLUC)
3
CITRANATAL
DHA (ALGAL OIL)
3
CITRANATAL
HARMONY (IRON
FUM)
3
classic prenatal
0
ACA; OTC
c-nate dha
1
3
ACA; OTC
COMPLETE
FORMULATION
D3000
COMPLETE
FORMULATION
PEDIATRIC
3
complete natal dha
1
completenate
1
CONCEPT DHA
3
Vitamins & Hematinics
ACTIVE FE
3
ACTIVE OB
3
ANIMI-3 WITH
VITAMIN D
3
ATABEX EC
3
b complex 100
1
PA
b complex-vitamin
b12
0
ACA; OTC
b complex-vitamin cfolic acid
0
BACMIN
3
balanced b-100
complex
0
bal-care dha
1
BAL-CARE DHA
ESSENTIAL
3
b-complex with
vitamin c
0
ACA; OTC
98
Restrictions /
Limits
ACA; OTC
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
CONCEPT OB
3
ESCAVITE D
3
corvita
1
ESCAVITE LQ
3
corvita 150
1
2
CORVITE
3
EXPECTA
PRENATAL
CORVITE 150
3
EXTRA-VIRT
PLUS DHA
3
CORVITE FE
3
FA-8
3
CORVITE FREE
3
fabb
1
cyanocobalamin
(vitamin b-12)
1
fe c plus
1
dexferrum
1
FERAHEME
3
dialyvite
1
FERIVA 21-7
TABLET
3
DIALYVITE 3000
3
3
FERIVA FA
(SUMALATE)
3
DIALYVITE 5000
dialyvite 800
0
ferocon
1
DIALYVITE 800
WITH IRON
3
3
DIALYVITE
SUPREME D
3
FERRALET 90
DUAL-IRON
DELIVERY
ferraplus 90
1
dothelle dha
1
ferrex 150 forte
1
DRISDOL
3
ferrex 150 forte plus
1
DUET DHA
BALANCED
3
ferrex 28
1
ferrocite plus
1
DUET DHA ECOM 3
3
ferrogels forte
1
DUET DHA WITH
OMEGA-3
3
FLORIVA
3
3
DURACHOL
3
FLORIVA
(FLUORIDEVITAMIN D3)
ELDERCAPS
3
FLORIVA PLUS
3
elite-ob
1
FLUORABON
3
ENLYTE
(FERROUS
GLYCINE)
3
FLUOR-A-DAY
3
ergocalciferol
(vitamin d2)
1
ESCAVITE
3
PA
ACA; OTC
Restrictions /
Limits
OTC
OTC
PA
99
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
ACA
folic acid oral tablet
1 mg
1
folic acid oral tablet
400 mcg, 800 mcg
0
folic acid-vit b6-vit
b12
1
folivane-f
1
folivane-ob
1
folivane-plus
1
folplex 2.2
1
foltabs 800
0
FOLTRATE
3
full spectrum bvitamin c
0
FUSION PLUS
3
hematinic plus
vit/minerals
1
hematinic/folic acid
1
hematogen
1
hematogen fa
1
fluor-a-day (with
xylitol) oral
tablet,chewable 0.25
mg f (0.55 mg)236.79mg, 0.5 mg f
(1.1 mg)-236.79 mg
0
fluor-a-day (with
xylitol) oral
tablet,chewable 1
mg f (2.2 mg)-236.79
mg
1
FLUORITAB
ORAL DROPS
0.125 MG FLUOR
(0.275 MG)/DROP
3
fluoritab oral drops
0.25 mg fluorid
(0.55 mg)/drop
1
fluoritab oral
tablet,chewable 0.5
mg fluoride (1.1 mg)
0
fluoritab oral
tablet,chewable 1
1
FLURA-DROPS
3
hematogen forte
1
focalgin 90 dha
1
HEMATRON
3
focalgin ca
1
HEMATRON-AF
3
focalgin dss
1
HEMAX
3
folbecal
1
hemenatal ob
1
folbee
1
hemenatal ob + dha
1
folbee ar
1
hemetab
1
folbee plus
1
HEMOCYTE-F
3
FOLET DHA
3
HEMOCYTE-PLUS
3
FOLET ONE
3
hydroxocobalamin
1
FOLGARD OS
3
ICAR-C PLUS
3
FOLGARD RX
3
iferex 150 forte
1
folic acid injection
1
inatal advance
1
ACA
PA
100
Restrictions /
Limits
ACA; OTC
ACA; OTC
ACA; OTC
PA
Drug Name
Tier
Restrictions /
Limits
inatal gt
1
inatal ultra
1
INFANATE
BALANCE
3
infed
1
PA
INFUVITE ADULT
3
PA
INFUVITE
PEDIATRIC
3
PA
INJECTAFER
Drug Name
Tier
Restrictions /
Limits
MAXFE (FOLATEDOCUSATE)
3
MAXINATE
3
mecobal-levomefolat
ca-b6 phos
1
METANX
3
MULTICHEW
3
multi-delyn with iron
1
3
multigen folic
1
INTEGRA F
3
multigen plus
1
INTEGRA PLUS
3
0
ACA
IRON
3
multi-vit with
fluoride-iron
iron aspgly,ps-cb12-fa-ca-suc
1
multi-vitamin with
fluoride oral drops
0
ACA
IROSPAN 24/6
3
0
ACA
levomefolate dha
1
levomefolatepnv
1
multi-vitamin with
fluoride oral
mg, 0.5 mg
l-methylfolate pnv
dha
1
1
lozi-flur
1
multi-vitamin with
fluoride oral
tablet,chewable 1
mg
ludent fluoride oral
mg fluorid (0.55
mg), 0.5 mg fluoride
(1.1 mg)
0
multivitamins with
fluoride oral
mg, 0.5 mg
0
1
multivitamins with
fluoride oral
tablet,chewable 1
mg
1
ludent fluoride oral
tablet,chewable 1
M.V.I. PEDIATRIC
2
PA
0
M.V.I.-12
(WITHOUT
VITAMIN K)
3
PA
mvc-fluoride oral
mg, 0.5 mg
1
macnatal cn dha
1
mvc-fluoride oral
tablet,chewable 1
mg
MARNATAL-F
3
M-VIT
3
MAXARON
FORTE
3
myferon 150 forte
1
ACA
OTC
ACA
ACA
101
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
NEXAVIR
3
NICOMIDE
3
NICOMIDE
(SELENIUMCHROMIUM)
3
nicotinamide
1
NIRON
KOMPLETE
3
NIVA-FOL
3
NIVA-PLUS
3
NUFERA
3
NUTRICAP
3
OB COMPLETE
3
OB COMPLETE
GOLD
3
OB COMPLETE
ONE
3
OB COMPLETE
PETITE
3
OB COMPLETE
PREMIER
3
MYKIDZ IRON
FLUORIDE
3
mynatal
1
mynatal advance
1
mynatal plus
1
mynatal-z
1
mynate 90 plus
1
mynephrocaps
1
NATA KOMPLETE
3
NATACHEW (FE
BIS-GLYCINATE)
3
natalvirt 90 dha
1
natalvirt ca
1
NATALVIT
3
NATELLE ONE
3
natural b-100
complex
0
NEEVO
3
NEEVODHA
(WITH ALGAL
OIL)
3
1
OB COMPLETE
WITH DHA
3
nephplex rx
NEPHROCAPS
3
obstetrix dha
1
NEPHROCAPS QT
3
OBSTETRIX EC
3
NEPHRON FA
3
OBTREX
3
NEPHRO-VITE
3
OBTREX DHA
3
nephro-vite rx
1
O-CAL FA
3
NESTABS
3
3
NESTABS ABC
3
O-CAL
PRENATAL
NESTABS DHA
3
3
NEURIN-SL
3
ONE A DAY
WOMEN'S
PRENATAL DHA
newgen
1
NEXA PLUS
3
ACA; OTC
OTC
102
Restrictions /
Limits
PA
OTC
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
OTC
pr natal 430
1
pr natal 430 ec
1
PREFERA-OB
3
PREFERA-OB ONE
3
PREFERA-OB
PLUS DHA
3
prena1 chew
1
prena1 pearl
1
prenaissance
1
prenaissance 90 dha
1
prenaissance
harmony dha
1
prenaissance next
1
PRENAISSANCE
NEXT-B
3
prenaissance plus
1
1
Restrictions /
Limits
ONE DAILY
PRENATAL ORAL
COMBO PACK 28
MG IRON- 800
MCG
3
one daily prenatal
oral combo pack 28800-440 mg-mcg-mg
0
ortho d
1
PAIRE OB PLUS
DHA
3
PED
MULTIVITAMINSA,B,D,E,K,ZN
3
perry prenatal
0
pnv 29-1
1
PNV FOLIC ACID
+ IRON
3
pnv ob+dha
1
pnv-dha
1
prenaissance
promise
pnv-dha + docusate
1
PRENATA
3
pnv-ferrous
fumarate-docu-fa
1
prenatabs fa
1
prenatabs rx
1
pnv-omega
1
prenatal
0
ACA; OTC
pnv-select
1
PRENATAL + DHA
2
OTC
pnv-total
1
prenatal complete
0
ACA; OTC
pnv-vp-u
1
prenatal formula
0
ACA; OTC
poly-iron 150 forte
1
prenatal one daily
0
ACA; OTC
POLY-VI-FLOR
3
prenatal plus
1
POLY-VI-FLOR FS
3
1
POLY-VI-FLOR
WITH IRON
3
prenatal plus
(calcium carb)
0
ACA; OTC
poly-vitamin with
iron
0
prenatal vit#96ferrous fum-fa
prenatal vitamin
0
ACA; OTC
pr natal 400
1
1
pr natal 400 ec
1
prenatal vitamin
plus low iron
ACA; OTC
ACA; OTC
ACA; OTC
103
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
Restrictions /
Limits
prenatal-u
1
purevit dualfe plus
1
PRENATE AM
3
3
PRENATE
CHEWABLE
3
QUFLORA
PEDIATRIC
3
PRENATE DHA
(FERR ASP
GLYCIN)
3
QUFLORA
PEDIATRIC
DROPS
relnate dha
1
PRENATE ELITE
(IRON ASP GLYC)
3
renal caps
1
RENAL VITAMIN
3
OTC
PRENATE
ENHANCE
3
rena-vite
0
ACA; OTC
PRENATE
ESSENTIAL(IRONASP-GL)
3
rena-vite rx
1
RENAX
3
reno caps
1
PRENATE MINI
3
REVESTA
3
PRENATE MINI
(FERR ASP
GLYCIN)
3
RIGHT STEP
PRENATAL
VITAMINS
3
OTC
PRENATE PIXIE
3
risacal-d
0
ACA; OTC
PRENATE
RESTORE
3
R-NATAL OB
3
PRENATE STAR
3
rulavite dha
1
preplus
1
SELECT-OB
3
PREQUE 10
3
SELECT-OB +
DHA
3
pretab
1
se-natal 19
1
PROFERRINFORTE
3
se-natal 19 (with
docusate)
1
PROTECT BONE
3
se-tan dha
1
PROTECT IRON
3
se-tan plus
1
PROTECT NATAL
3
SIDEROL
3
PROVIDA DHA
3
3
sodium fluoride oral
drops
0
PROVIDA OB
PURALOR CI
3
PUREFE OB PLUS
3
PUREFE PLUS
3
104
ACA
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
ACA
tl-hem 150
1
TRICARE
2
TRICARE
PRENATAL
COMPLEAT
3
TRICARE
PRENATAL DHA
ONE
3
TRICARE
PRENATAL WITH
DHA
3
tricon
1
TRIFERIC
3
trigels-f forte
1
trinatal gt
1
Restrictions /
Limits
mg fluorid (0.55
mg), 0.5 mg fluoride
(1.1 mg)
0
tablet,chewable 1
1
SOFTGELS
MULTIVITA,B,D,E,K,ZN
3
stress formula
0
ACA; OTC
stress formula with
iron
0
ACA; OTC
stress formula with
iron(sulf)
0
strovite
1
trinatal rx 1
1
STROVITE FORTE
3
trinate
1
STROVITE ONE
3
triphrocaps
1
strovite plus
1
TRISTART DHA
3
SUPERVITE
3
tri-tabs dha
1
SUPERVITE (EC)
3
triveen-duo dha
1
SYNAGEX
3
TRI-VI-FLOR
3
TANDEM F
3
ACA
3
tri-vit with fluoride
and iron
0
TANDEM PLUS
taron forte
1
0
ACA
taron-c dha
1
tri-vitamin with
fluoride
taron-prex prenataldha
1
trust natal dha
1
UDAMIN SP
3
TEXAVITE LQ
3
ultimatecare one
1
THRIVITE RX
3
ultimatecare one nf
1
thrivite-19
1
v-c forte
1
tl gard rx
1
vemavite-prx-2
1
tl g-fol os
1
VENOFER
3
tl icon
1
vic-forte
1
ACA; OTC
PA
PA
PA
105
Drug Name
Tier
Restrictions /
Limits
vinate care
1
VITAFOL NANO
3
vinate dha
1
VITAFOL ULTRA
3
VINATE DHA RF
3
vitafol-ob
1
vinate ii
1
3
vinate m
1
VITAFOLOB+DHA
vinate one
1
VITAFOL-ONE
3
vinate ultra
1
VITAFOL-PLUS
3
virt-advance
1
vitafol-pn (ud)
1
virt-bal dha
1
VITAL-D RX
3
virt-c dha
1
VITAMAX
2
VIRT-CAPS
3
VITAMED MD
ONE RX
3
virt-care one
1
1
VITAMED MD
PLUS RX
3
virt-gard
virt-nate
1
3
virt-nate dha
1
VITAMEDMD
REDICHEW RX
virt-pn
1
vitamin d3
0
ACA; OTC
virt-pn dha
1
vitamins a,c,d and
fluoride
0
ACA
virt-pn plus
1
OTC
3
VITAMINS B
COMPLEX
2
VIRTPREX
virt-select
1
VITAPEARL
3
virt-vite
1
VITA-RESPA
3
virt-vite gt
1
VIVA DHA
3
VIRT-VITE PLUS
3
vol-care rx
1
vit 3
1
vol-nate
1
vit b complex-folic
acid
0
ACA; OTC
vol-plus
1
vol-tab rx
1
VITA-BEE WITH C
3
OTC
VP CH ULTRA
3
VITAFOL
3
vp-ch plus
1
VITAFOL FE+
(WITH
DOCUSATE)
3
vp-ch-pnv
1
vp-era ob plus
1
VITAFOL
GUMMIES
3
vp-ggr-b6
1
vp-heme ob
1
106
Drug Name
Tier
Restrictions /
Limits
Drug Name
Tier
vp-heme one
1
VP-PNV-DHA
3
vp-vite rx
1
XYZBAC
3
zatean-ch
1
zatean-pn dha
1
zatean-pn plus
1
zavara
1
zingiber
1
Restrictions /
Limits
107
Index
1
1ST TIER UNIFINE PENTIPS
.......................................... 55
1ST TIER UNILET
COMFORTOUCH ........... 55
8
8-MOP .................................. 40
A
abacavir .................................. 3
abacavir-lamivudinezidovudine .......................... 3
ABELCET .............................. 3
ABILIFY .............................. 25
ABILIFY MAINTENA ........ 25
ABRAXANE........................ 12
ABSORICA.......................... 42
ABSTRAL............................ 21
acamprosate .......................... 47
ACANYA ............................. 42
acarbose ................................ 67
ACCOLATE......................... 93
ACCU-CHEK ADVANTAGE
TEST ................................ 51
ACCU-CHEK AVIVA......... 51
ACCU-CHEK AVIVA
CONNECT METER ........ 55
ACCU-CHEK AVIVA PLUS
METER ............................ 55
ACCU-CHEK AVIVA PLUS
TEST STRP ...................... 51
ACCU-CHEK COMBO
SYSTEM .......................... 55
ACCU-CHEK COMPACT
TEST ................................ 51
ACCU-CHEK FASTCLIX .. 55
ACCU-CHEK NANO .......... 55
ACCU-CHEK SAFE-T-PRO
.......................................... 55
ACCU-CHEK SMARTVIEW
CONTRL SOL ................. 55
ACCU-CHEK SMARTVIEW
TEST STRIP .................... 51
ACCU-CHEK SOFTCLIX
LANCET DEV ................. 55
ACCU-CHEK SOFTCLIX
LANCETS ........................ 55
ACCU-CHEK VOICEMATE
.......................................... 55
ACCUPRIL .......................... 30
ACCURETIC ....................... 30
ACCUTREND GLUCOSE .. 51
ACCUTREND GLUCOSE
CONTROL ....................... 55
acebutolol ............................. 30
ACEON ................................ 30
acetaminophen-codeine ........ 21
acetasol hc ............................ 50
acetazolamide ....................... 89
acetazolamide sodium .......... 89
acetic acid ....................... 48, 50
acetic acid-aluminum acetate50
acetylcysteine ....................... 93
ACIPHEX ............................. 73
ACIPHEX SPRINKLE......... 73
acitretin ................................. 38
ACTEMRA .......................... 80
ACTHAR H.P. ..................... 50
ACTHIB (PF) ....................... 76
ACTHREL............................ 65
ACTICLATE ........................ 10
ACTIGALL .......................... 70
ACTI-LANCE LANCETS ... 55
ACTIMMUNE ..................... 76
ACTIQ .................................. 21
ACTIVE FE .......................... 98
ACTIVE OB ......................... 98
ACTIVELLA........................ 81
ACTONEL ..................... 48, 80
ACTOPLUS MET ................ 67
ACTOPLUS MET XR ......... 67
ACTOS ................................. 67
acuicyn.................................. 88
ACULAR.............................. 89
ACULAR LS ........................ 89
ACURA TEST STRIPS ....... 51
ACUVAIL (PF) .................... 89
acyclovir ........................... 3, 45
acyclovir sodium .................... 3
ACZONE .............................. 42
ADACEL(TDAP
ADOLESN/ADULT)(PF) 76
ADAGEN ............................. 48
ADALAT CC ....................... 30
108
adapalene .............................. 42
ADASUVE ........................... 25
ADCETRIS........................... 12
ADCIRCA ............................ 93
ADDERALL.........................25
ADDERALL XR .................. 25
adefovir ...................................3
ADEMPAS ........................... 93
ADJUSTABLE LANCING
DEVICE ........................... 55
ADOXA ................................10
ADRENACLICK ................. 90
adrenalin ............................... 90
adrucil ................................... 12
ADVAIR DISKUS ............... 93
ADVAIR HFA...................... 93
ADVANCED GLUC METER
TEST STRIP ..................... 51
ADVANCED GLUCOSE
METER............................. 55
ADVANCED LANCING
DEVICE ........................... 55
ADVANCED TRAVEL
LANCETS ........................ 55
ADVATE .............................. 35
ADVOCATE BLOOD
GLUCOSE MONITOR ....55
ADVOCATE LANCET ....... 55
ADVOCATE PEN NEEDLES
.......................................... 55
ADVOCATE RAPID-SAFE
LANCING ........................ 55
ADVOCATE REDI-CODE.. 51
ADVOCATE REDI-CODE
GLU MONITOR .............. 55
ADVOCATE TEST STRIPS51
ADZENYS XR-ODT ........... 25
AEROSPAN ......................... 93
afeditab cr ............................. 30
AFINITOR ........................... 12
AFINITOR DISPERZ .......... 12
AFLURIA 2012-2013 .......... 76
AFLURIA 2012-2013 (PF) ..76
AFLURIA 2013-2014 ..........76
AFLURIA 2013-2014 (PF) ..76
AFLURIA 2014-2015 ..........76
AFLURIA 2014-2015 (PF) ..76
AFLURIA 2015-2016 .......... 76
AFLURIA 2015-2016 (PF) .. 76
AFREZZA ............................ 65
AFSTYLA ............................ 35
AFTERA .............................. 83
AGAMATRIX AMP GLUC
MONITOR SYS ............... 55
AGAMATRIX AMP TEST
STRIPS ............................. 51
AGGRENOX ....................... 35
AGRYLIN ............................ 48
AKNE-MYCIN .................... 42
AKTEN (PF) ........................ 88
AKYNZEO........................... 70
ala-cort .................................. 45
ALA-SCALP ........................ 45
ALBENZA ............................. 7
albuterol sulfate .................... 93
ALCAINE ............................ 88
alclometasone ....................... 45
ALDACTAZIDE .................. 30
ALDACTONE ..................... 30
ALDARA ............................. 76
ALDURAZYME .................. 65
ALECENSA ......................... 12
alendronate ..................... 48, 80
ALEVICYN ANTIPRURITIC
.......................................... 40
ALFERON N........................ 76
alfuzosin ............................... 95
ALIMTA .............................. 12
ALINIA .................................. 7
ALKERAN ........................... 12
ALLFEN CDX ..................... 91
allopurinol ............................ 80
ALLZITAL........................... 21
almotriptan malate ................ 19
ALOCRIL............................. 88
ALODOX ............................. 87
ALOMIDE ........................... 88
aloprim ................................. 80
ALORA ................................ 81
alosetron ............................... 70
ALOXI ................................. 70
ALPHAGAN P ..................... 90
ALPHANATE ...................... 35
ALPHANINE SD ................. 35
alprazolam ............................ 25
alprazolam intensol .............. 25
alprostadil ............................. 95
ALREX ................................. 90
ALSUMA ............................. 19
ALTABAX ........................... 44
altacaine ................................ 88
ALTACE .............................. 30
altafluor ................................ 88
altavera (28) .......................... 83
ALTERNATE SITE LANCET
.......................................... 55
ALTERNATE SITE
LANCING DEVICE ........ 55
ALTOPREV ......................... 37
ALUVEA.............................. 40
ALVESCO............................ 93
alyacen 1/35 (28) .................. 83
alyacen 7/7/7 (28) ................. 83
amantadine hcl ........................ 3
AMARYL............................. 67
ambi 10peh-400gfn-20dm .... 91
AMBIEN .............................. 25
AMBIEN CR ........................ 25
AMBIFED ............................ 91
AMBIFED DM..................... 91
AMBISOME .......................... 3
amcinonide ........................... 45
AMERGE ............................. 19
amethia ................................. 83
amethia lo ............................. 83
amethyst................................ 83
AMICAR .............................. 35
amifostine crystalline ........... 11
amikacin ................................. 7
amiloride............................... 30
amiloride-hydrochlorothiazide
.......................................... 30
aminocaproic acid................. 35
amiodarone ........................... 30
AMITIZA ............................. 70
amitriptyline ......................... 25
amitriptyline-chlordiazepoxide
.......................................... 25
amlodipine ............................ 30
amlodipine-atorvastatin ........ 37
amlodipine-benazepril .......... 30
amlodipine-valsartan ............ 30
amlodipine-valsartan-hcthiazid
.......................................... 30
AMMONIUM CHLORIDE . 95
amoxapine............................. 25
amoxicil-clarithromy-lansopraz
.......................................... 73
amoxicillin .............................. 9
AMOXICILLIN ..................... 9
amoxicillin-pot clavulanate .... 9
AMPHADASE ..................... 48
amphotericin b ........................ 3
ampicillin ................................ 9
ampicillin sodium ................... 9
ampicillin-sulbactam .............. 9
AMPYRA ............................. 20
AMRIX ................................. 20
ANADROL-50 ..................... 65
ANAFRANIL ....................... 25
anagrelide ............................. 48
ANA-LEX KIT ..................... 70
ANALPRAM E .................... 70
ANALPRAM-HC ................. 70
ANALPRAM-HC SINGLES70
ANAPROX DS ..................... 24
anaspaz ................................. 69
anastrozole ............................ 12
ANCOBON ............................ 3
ANDRODERM .................... 65
ANDROGEL .................. 65, 66
ANDROID ............................ 66
androxy ................................. 66
ANGELIQ ............................ 81
ANIMI-3 WITH VITAMIN D
.......................................... 98
ANORO ELLIPTA ............... 93
ANTABUSE ......................... 48
ANTARA ............................. 37
antipyrine-benzocaine........... 50
ANTIVERT .......................... 70
anucort-hc ............................. 70
ANUSOL-HC ....................... 70
ANZEMET ........................... 70
apexicon e ............................. 45
APIDRA ............................... 65
APIDRA SOLOSTAR..........65
APLENZIN...........................26
APOKYN ............................. 18
APOP .................................... 42
apraclonidine ........................ 90
apri ........................................ 83
APRISO ................................ 70
APTENSIO XR .................... 26
109
APTIOM............................... 16
APTIVUS ............................... 3
AQUA GLYCOLIC HC....... 45
AQUA LANCE LANCING
DEVICE ........................... 55
ARALAST NP ..................... 48
aranelle (28).......................... 84
ARANESP (IN
POLYSORBATE) ............ 75
ARAVA................................ 80
arbinoxa ................................ 90
ARCALYST ......................... 76
ARCAPTA NEOHALER..... 93
ARGATROBAN .................. 35
ARGATROBAN IN 0.9 %
SOD CHLOR ................... 35
ARGATROBAN IN NACL
(ISO-OS) .......................... 35
ARICEPT ............................. 20
ARIMIDEX .......................... 12
aripiprazole ........................... 26
ARISTADA.......................... 26
ARIXTRA ............................ 35
armodafinil ........................... 26
ARMOUR THYROID ......... 69
ARNUITY ELLIPTA ........... 93
AROMASIN......................... 12
ARRANON .......................... 12
ARTHROTEC 50 ................. 24
ARTHROTEC 75 ................. 24
ARZERRA ........................... 12
ASACOL .............................. 70
ASACOL HD ....................... 70
ascomp with codeine ............ 21
ashlyna .................................. 84
ASMANEX HFA ................. 93
ASMANEX TWISTHALER 93
aspirin ................................... 24
aspirin-dipyridamole ............ 35
ASSURE 4 STRIPS ............. 51
ASSURE LANCE ................ 55
ASSURE LANCE PLUS ..... 55
ASSURE PLATINUM ... 52, 55
ASSURE PRISM MULTI
METER ............................ 56
ASSURE PRISM MULTI
STRIP ............................... 52
ASTAGRAF XL .................. 12
ASTEPRO ............................ 49
ASTRAMORPH-PF ............. 21
ATABEX EC ........................ 98
ATACAND .......................... 30
ATACAND HCT ................. 30
ATELVIA ............................. 80
atenolol ................................. 30
atenolol-chlorthalidone ......... 30
ATGAM ............................... 76
ATIVAN ............................... 26
ATOPICLAIR ...................... 40
atorvastatin ........................... 37
atovaquone.............................. 7
atovaquone-proguanil ............. 7
ATRALIN ............................ 42
ATRAPRO CP ..................... 40
ATRAPRO HYDROGEL .... 40
ATRIPLA ............................... 3
ATROPEN............................ 47
atropine ........................... 69, 88
ATROVENT ........................ 49
ATROVENT HFA ............... 93
AUBAGIO............................ 75
aubra ..................................... 84
AUGMENTIN ........................ 9
AUGMENTIN ES-600 ........... 9
AUGMENTIN XR ................. 9
AURAX ................................ 50
auroguard .............................. 50
AURSTAT............................ 40
AURYXIA............................ 70
AUTOJECT 2 INJECTION
DEVICE ........................... 56
AUTO-LANCET MINI........ 56
AUTOLET IMPRESSION
LANC DEV ...................... 56
AUTOLET LANCING
DEVICE ........................... 56
AUTOPEN 2 TO 32 UNITS 56
AVALIDE ............................ 30
AVANDIA ........................... 67
AVAPRO.............................. 30
avar ....................................... 42
AVAR ................................... 42
AVAR LS ............................. 42
AVAR-E GREEN................. 42
AVAR-E LS ......................... 42
AVASTIN ............................ 12
AVC VAGINAL .................. 83
AVEED ................................ 66
110
AVELOX .............................. 10
AVELOX ABC PACK ......... 10
AVELOX IN NACL (ISOOSMOTIC) ....................... 10
AVENOVA .......................... 88
aviane .................................... 84
avidoxy ................................. 10
AVIDOXY DK ..................... 10
avita ...................................... 42
avo cream.............................. 40
AVODART........................... 95
AVONEX ............................. 75
AVONEX (WITH ALBUMIN)
.......................................... 75
AVYCAZ ............................... 5
AXERT ................................. 19
AXIRON............................... 66
AYGESTIN .......................... 81
azacitidine ............................. 12
AZACTAM ............................ 7
AZACTAM IN DEXTROSE
(ISO-OSM) ......................... 7
AZASAN .............................. 12
AZASITE ............................. 87
azathioprine .......................... 12
azathioprine sodium..............12
azelastine ........................49, 88
AZELEX...............................42
AZILECT ............................. 18
azithromycin ........................... 6
AZOPT ................................. 89
AZOR ................................... 30
aztreonam ............................... 7
AZULFIDINE ...................... 70
AZULFIDINE EN-TABS .... 70
azuphen mb ........................... 95
azurette (28) .......................... 84
B
b complex 100 ...................... 98
b complex-vitamin b12 ......... 98
b complex-vitamin c-folic acid
.......................................... 98
baciim ..................................... 7
bacitracin .......................... 7, 87
bacitracin-polymyxin b ......... 87
baclofen ................................ 20
BACMIN .............................. 98
BACTRIM ............................ 10
BACTRIM DS ...................... 10
BACTROBAN NASAL ....... 49
balanced b-100 complex....... 98
bal-care dha .......................... 98
BAL-CARE DHA
ESSENTIAL..................... 98
balsalazide ............................ 70
balziva (28)........................... 84
BANZEL .............................. 16
BARACLUDE ....................... 3
BCG VACCINE, LIVE (PF) 76
b-complex with vitamin c..... 98
BD AUTOSHIELD PEN
NEEDLE .......................... 56
BD CURVED TONSIL
REUSABLE ..................... 56
BD ECLIPSE........................ 56
BD FILTER NEEDLE-5
MICRON .......................... 56
BD INSULIN PEN NEEDLE
UF SHORT....................... 56
BD INTEGRA NEEDLE ..... 56
BD LANCET DEVICE ........ 56
BD MICROTAINER
LANCET .......................... 56
BD NOKOR ADMIX
NEEDLE .......................... 56
BD PRECISIONGLIDE....... 56
BD PRECISIONGLIDE NONSTERILE .......................... 56
bd pre-filled normal saline ... 48
BD QUINCKE SPINAL
NEEDLE .......................... 56
BD SAFETYGLIDE NEEDLE
.......................................... 56
BD SPECIALTY USE
NEEDLES ........................ 56
BD ULTRA FINE LANCETS
.......................................... 56
BD ULTRA-FINE NANO
PEN NEEDLES................ 56
BD WHITACRE SPINAL
NEEDLE .......................... 56
BD YALE REUSABLE REG
METAL ............................ 56
BEBULIN............................. 35
BECONASE AQ .................. 93
bekyree (28).......................... 84
BELBUCA ........................... 21
BELEODAQ ........................ 12
belladonna alkaloids-opium . 69
belladonna-opium ................. 69
BELSOMRA ........................ 26
benazepril ............................. 31
benazepril-hydrochlorothiazide
.......................................... 31
BENDEKA ........................... 12
BENEFIX ............................. 35
BENICAR ............................ 31
BENICAR HCT ................... 31
BENLYSTA ......................... 80
BENSAL HP .................. 39, 44
BENTYL .............................. 69
BENZACLIN ....................... 42
BENZACLIN PUMP ........... 42
BENZAMYCIN ................... 42
BENZAMYCINPAK ........... 42
BENZEFOAM...................... 42
BENZEFOAM ULTRA ....... 42
benzepro ............................... 42
BENZEPRO
(MICROSPHERES) ......... 42
benzonatate ........................... 91
benzoyl peroxide .................. 42
benztropine ........................... 18
BEPREVE ............................ 88
BERINERT .......................... 93
BESIVANCE........................ 87
BETADINE OPHTHALMIC
PREP ................................ 87
BETAGAN ........................... 87
betamethasone dipropionate . 45
betamethasone valerate......... 45
betamethasone, augmented ... 45
BETAPACE ......................... 30
BETAPACE AF ................... 30
BETASERON ...................... 75
betaxolol ......................... 31, 87
bethanechol chloride............. 95
BETHKIS ............................... 7
BETIMOL ............................ 87
BETOPTIC S ........................ 87
BEVESPI AEROSPHERE ... 93
bexarotene ............................ 12
BEXSERO (PF) .................... 76
BEYAZ................................. 84
BG-STAR ............................. 52
BIAFINE EMULSION......... 40
BIAXIN .................................. 6
bicalutamide ......................... 12
BICILLIN C-R ....................... 9
BICILLIN L-A ....................... 9
BICNU .................................. 12
BIDIL ................................... 31
BIFERA RX ......................... 98
BILTRICIDE .......................... 7
BINOSTO ............................. 80
BIONIME RIGHTEST
GM300 SYSTEM ............. 56
BIONIME RIGHTEST TEST
STRIPS ............................. 52
bisoprolol fumarate ............... 31
bisoprolol-hydrochlorothiazide
.......................................... 31
BIVIGAM............................. 77
bleomycin ............................. 12
BLEPH-10 ............................ 90
BLEPHAMIDE .................... 90
BLEPHAMIDE S.O.P. ......... 90
BLINCYTO .......................... 12
blisovi 24 fe .......................... 84
blisovi fe 1.5/30 (28) ............ 84
blisovi fe 1/20 (28) ............... 84
BLOOD GLUCOSE TEST .. 52
BLOOD-GLUCOSE METER
.......................................... 56
BLUNT NEEDLE,
DISPOSABLE .................. 56
BONIVA............................... 80
BOOSTRIX TDAP ............... 77
BOSULIF ............................. 12
bp 10-1 .................................. 42
bp-50% urea.......................... 40
bpo ........................................ 42
BRAVELLE ......................... 66
BREEZE 2 TEST STRIPS ...52
BREO ELLIPTA .................. 93
BREVIBLOC ....................... 31
BREVIBLOC IN NACL (ISOOSM) ................................ 31
BREVICON (28) .................. 84
briellyn .................................. 84
BRILINTA ........................... 35
brimonidine........................... 90
BRISDELLE......................... 26
BRIVIACT ........................... 16
BROMFED DM ................... 91
bromfenac ............................. 89
111
bromocriptine ....................... 18
brompheniramine-pseudoephdm ..................................... 91
BROVANA .......................... 93
BUCALSEP ......................... 44
budesonide...................... 70, 93
BULLSEYE MINI SAFETY
LANCETS ........................ 56
bumetanide ........................... 31
BUNAVAIL ......................... 24
BUPAP ................................. 21
BUPHENYL......................... 48
BUPRENEX ......................... 21
buprenorphine hcl ................. 21
buprenorphine-naloxone....... 24
bupropion hcl........................ 26
buspirone .............................. 26
BUSULFEX ......................... 12
butalbital compound ............. 21
butalbital compound w/codeine
.......................................... 21
butalbital-acetaminop-caf-cod
.......................................... 21
butalbital-acetaminophen ..... 21
butalbital-acetaminophen-caff
.......................................... 21
butalbital-aspirin-caffeine .... 21
BUTISOL ............................. 26
butorphanol tartrate .............. 24
BUTRANS ........................... 21
BYDUREON........................ 67
BYETTA .............................. 67
BYSTOLIC .......................... 31
C
cabergoline ........................... 66
CABOMETYX..................... 12
CADEAU DHA.................... 98
CADUET.............................. 37
CAFERGOT ......................... 19
caffeine citrated .................... 48
CALAN ................................ 31
CALAN SR .......................... 31
calcipotriene ......................... 38
calcipotriene-betamethasone 38
calcitonin (salmon) ............... 66
calcitrene .............................. 38
calcitriol .......................... 38, 66
calcium 500 with d ............... 96
calcium acetate ..................... 70
calcium carb and citrate-vitd3
.......................................... 96
calcium citrate + d ................ 96
calcium citrate-vitamin d2 .... 96
calcium folinate (leucovorin)11
calcium pnv .......................... 98
calcium-folic acid-vitamin d 98
CALDOLOR ........................ 24
CAMBIA .............................. 24
camila ................................... 81
CAMPATH .......................... 12
CAMPTOSAR...................... 12
camrese ................................. 84
camrese lo ............................. 84
CANASA.............................. 70
CANCIDAS............................ 3
candesartan ........................... 31
candesartan-hydrochlorothiazid
.......................................... 31
CANTIL ............................... 69
capacet .................................. 21
CAPASTAT ........................... 7
CAPCOF .............................. 91
capecitabine .......................... 12
CAPEX ................................. 45
CAPITAL WITH CODEINE
.......................................... 21
CAPRELSA.......................... 12
captopril ................................ 31
captopril-hydrochlorothiazide
.......................................... 31
captracin ............................... 40
CARAC ................................ 40
carafate ................................. 73
CARAFATE ......................... 73
CARBAGLU ........................ 48
carbamazepine ...................... 16
CARBATROL ...................... 16
carbidopa .............................. 18
carbidopa-levodopa .............. 18
carbidopa-levodopaentacapone ........................ 18
carbinoxamine maleate ......... 90
carboplatin ............................ 12
CARDENE IV ...................... 31
CARDENE IV IN
DEXTROSE ..................... 31
CARDENE IV IN SODIUM
CHLORIDE ...................... 31
112
CARDENE SR ..................... 31
CARDIOTEK-RX
(BIOPERINE)................... 98
CARDIZEM ......................... 31
CARDIZEM CD ................... 31
CARDIZEM LA ................... 31
CARDURA........................... 31
CARDURA XL .................... 31
CAREFINE PEN NEEDLE . 56
CAREONE THIN LANCET 56
CARESENS N ...................... 56
CARESENS N TEST STRIPS
.......................................... 52
CARESENS N VOICE......... 56
CARIMUNE NF
NANOFILTERED ............77
carisoprodol .......................... 20
carisoprodol-asa-codeine ...... 20
carisoprodol-aspirin .............. 20
CARNITOR .......................... 48
CARNITOR (SUGAR-FREE)
.......................................... 48
carteolol ................................ 87
carvedilol .............................. 31
CASODEX ........................... 12
CATAPRES .......................... 31
CATAPRES-TTS-1 .............. 31
CATAPRES-TTS-2 .............. 31
CATAPRES-TTS-3 .............. 31
CAYA CONTOURED ......... 81
CAYSTON ............................. 7
caziant (28) ........................... 84
CEDAX .................................. 5
cefaclor ................................... 5
cefadroxil ................................ 5
cefazolin ................................. 5
cefazolin in dextrose (iso-os).. 5
CEFAZOLIN IN DEXTROSE
(ISO-OS)............................. 5
cefdinir .................................... 5
cefditoren pivoxil.................... 5
cefepime ................................. 5
CEFEPIME IN DEXTROSE 5
% ......................................... 5
cefepime in dextrose,iso-osm . 5
cefixime .................................. 5
CEFOTAN .............................. 5
cefotaxime .............................. 5
cefotetan ................................. 5
CEFOTETAN IN
DEXTROSE, ISO-OSM..... 5
cefoxitin.................................. 5
cefoxitin in dextrose, iso-osm 5
cefpodoxime ........................... 5
cefprozil .................................. 5
ceftazidime ............................. 5
CEFTAZIDIME IN D5W ...... 5
ceftibuten ................................ 6
CEFTIN .................................. 6
ceftriaxone .............................. 6
CEFTRIAXONE .................... 6
ceftriaxone in dextrose,iso-os . 6
cefuroxime axetil .................... 6
cefuroxime sodium ................. 6
CEFUROXIME SODIUM ..... 6
CELEBREX ......................... 24
celecoxib............................... 24
CELEXA .............................. 26
CELLCEPT .......................... 12
CELLCEPT INTRAVENOUS
.......................................... 12
CELONTIN .......................... 16
cem-urea ............................... 40
CENESTIN........................... 81
CENTANY ........................... 44
CENTANY AT .................... 44
centergy ................................ 91
centratex ............................... 98
cephalexin............................... 6
CEPROTIN (BLUE BAR) ... 35
CEPROTIN (GREEN BAR) 35
CERDELGA......................... 66
CEREBYX ........................... 16
CEREZYME ........................ 66
CERVARIX VACCINE (PF)
.......................................... 77
CERVIDIL ........................... 83
CESAMET ........................... 70
CESINEX ............................. 69
CETRAXAL......................... 50
CETROTIDE........................ 66
cevimeline ............................ 48
CHANTIX ............................ 49
CHANTIX CONTINUING
MONTH BOX .................. 49
CHANTIX STARTING
MONTH BOX .................. 49
chateal................................... 84
CHEMET.............................. 48
CHENODAL ........................ 70
cheratussin ac ....................... 91
cheratussin dac ..................... 91
chewable multivit-a,b,d,e,k,zn
.......................................... 98
CHILDREN'S NASACORT 93
chloramphenicol sod succinate
............................................ 7
chlordiazepoxide hcl............. 26
chlordiazepoxide-clidinium .. 69
chloroquine phosphate ............ 7
chlorothiazide ....................... 31
chlorothiazide sodium .......... 31
chlorpromazine ..................... 26
chlorpropamide ..................... 67
chlorthalidone ....................... 31
chlorzoxazone....................... 20
choice-tabs ............................ 98
CHOLBAM .......................... 70
cholestyramine (with sugar) . 37
cholestyramine light ............. 37
choline,magnesium salicylate
.......................................... 24
CHOLOGRAFIN
MEGLUMINE.................. 48
chorionic gonadotropin, human
.......................................... 66
ciclodan ................................ 44
ciclopirox .............................. 44
ciclopirox-ure-camph-mentheuc .................................... 44
ciclopirox-vite-nail lacq remo
.......................................... 44
cidofovir ................................. 3
ciferex ................................... 98
cilostazol............................... 35
CILOXAN ............................ 87
cimetidine ............................. 74
cimetidine hcl ....................... 74
CIMZIA ................................ 70
CIMZIA POWDER FOR
RECONST ........................ 70
CINQAIR ............................. 93
CINRYZE ............................. 93
CIPRO .................................. 10
CIPRO HC ............................ 50
CIPRO IN D5W ................... 10
CIPRO XR ............................ 10
CIPRODEX .......................... 50
ciprofloxacin ......................... 10
ciprofloxacin (mixture) ......... 10
ciprofloxacin hcl ....... 10, 50, 87
ciprofloxacin in 5 % dextrose
.......................................... 10
ciprofloxacin lactate ............. 10
cisplatin................................. 12
citalopram ............................. 26
CITRANATAL (DUALIRON) ............................... 98
CITRANATAL 90 DHA
(ALGAL OIL) .................. 98
CITRANATAL ASSURE .... 98
CITRANATAL B-CALM (FE
GLUC) .............................. 98
CITRANATAL DHA
(ALGAL OIL) .................. 98
CITRANATAL HARMONY
(IRON FUM) .................... 98
cladribine .............................. 12
claravis .................................. 42
CLARINEX .......................... 90
CLARINEX-D 12 HOUR ....91
clarithromycin.........................6
classic prenatal......................98
cleansing wash ...................... 42
clemastine ............................. 90
CLEOCIN ......................... 7, 83
CLEOCIN IN 5 %
DEXTROSE ....................... 7
CLEOCIN T ......................... 42
CLEVER CHEK BLOOD
GLUCOSE ........................ 56
CLEVER CHEK LANCETS 57
CLEVER CHOICE
CLEVER CHOICE MICRO.57
CLEVER CHOICE MICRO
TEST STRIP .....................52
CLEVER CHOICE PRO 52, 57
CLEVER CHOICE TEST
STRIPS ............................. 52
CLEVER CHOICE VOICE+
TEST................................. 52
CLEVIPREX ........................ 31
CLICKFINE ......................... 57
CLIMARA ............................ 81
CLIMARA PRO ................... 81
113
CLIN SINGLE USE ............... 7
CLINDACIN ETZ................ 42
clindacin p ............................ 42
CLINDACIN PAC ............... 42
CLINDAGEL ....................... 42
clindamycin hcl ...................... 7
clindamycin in 5 % dextrose .. 7
clindamycin palmitate hcl ...... 7
clindamycin pediatric ............. 7
clindamycin phosphate .... 7, 42,
83
clindamycin-benzoyl peroxide
.......................................... 42
CLINDESSE ........................ 83
CLINPRO 5000 .................... 49
clobetasol .............................. 45
clobetasol-emollient ............. 46
CLOBEX .............................. 46
CLOCORTOLONE
PIVALATE ...................... 46
clodan ................................... 46
CLODERM .......................... 46
CLOLAR .............................. 12
clomiphene citrate ................ 66
clomipramine........................ 26
clonazepam ........................... 16
clonidine ............................... 31
clonidine hcl ................... 26, 31
clopidogrel ............................ 35
clorazepate dipotassium ....... 26
clorpres ................................. 31
CLORPRES.......................... 32
clotrimazole ...................... 3, 44
clotrimazole-betamethasone . 44
clozapine............................... 26
CLOZAPINE........................ 26
CLOZARIL .......................... 26
c-nate dha ............................. 98
CNL 8 NAIL ........................ 44
COAGUCHEK LANCETS .. 57
COAL TAR .......................... 39
COARTEM ............................ 7
CODAR AR ......................... 91
CODAR D ............................ 91
codeine sulfate ...................... 21
codeine-butalbital-asa-caff ... 21
codeine-guaifenesin.............. 91
COGENTIN ......................... 18
co-gesic................................. 21
COLAZAL ........................... 70
COLCHICINE ...................... 80
colchicine-probenecid .......... 80
COLCRYS............................ 80
COLESTID ........................... 37
COLESTID FLAVORED .... 37
colestipol .............................. 37
colistin (colistimethate na) ..... 7
colocort ................................. 70
COLOR LANCETS ............. 57
COLY-MYCIN M
PARENTERAL .................. 7
COLY-MYCIN S ................. 50
COLYTE WITH FLAVOR
PACKS ............................. 70
COMBIGAN ........................ 89
COMBIPATCH .................... 81
COMBIVENT RESPIMAT . 93
COMBIVIR ............................ 3
COMETRIQ ......................... 12
COMFORT EZ PEN
NEEDLES ........................ 57
COMFORT LANCETS ........ 57
COMPAZINE ....................... 70
COMPLERA .......................... 3
COMPLETE
FORMULATION D3000 . 98
COMPLETE
FORMULATION
PEDIATRIC ..................... 98
complete natal dha ................ 98
completenate ......................... 98
compro .................................. 70
COMTAN............................. 18
COMVAX (PF) .................... 77
CONCEPT DHA .................. 98
CONCEPT OB ..................... 99
CONCEPTROL .................... 83
CONCERTA ........................ 26
CONDYLOX........................ 40
constulose ............................. 70
CONTOUR LINK ................ 57
CONTOUR NEXT EZ
METER ............................ 57
CONTOUR NEXT METER 57
CONTOUR NEXT STRIPS . 52
CONTOUR NEXT USB
METER ............................ 57
CONTOUR TEST STRIPS .. 52
114
CONTROL G3 ..................... 52
CONTROL MONITORING
SYSTEM .......................... 57
CONZIP ................................ 24
COPAXONE ........................ 75
COPEGUS ............................ 75
CORDARONE ..................... 30
CORDRAN........................... 46
CORDRAN TAPE SMALL
ROLL ................................ 46
COREG................................. 32
COREG CR .......................... 32
CORGARD........................... 32
CORIFACT .......................... 35
CORLANOR ........................ 38
corlopam ............................... 32
cormax .................................. 46
CORTANE-B ....................... 40
cortane-b aqueous ................. 50
CORTEF ............................... 50
CORTENEMA ..................... 71
CORTIFOAM....................... 71
cortisone ............................... 51
CORTISPORIN .................... 44
CORTROSYN ...................... 51
corvita ................................... 99
corvita 150 ............................ 99
CORVITE ............................. 99
CORVITE 150 ...................... 99
CORVITE FE ....................... 99
CORVITE FREE .................. 99
CORZIDE ............................. 32
COSENTYX ......................... 39
COSENTYX (2 SYRINGES)
.......................................... 39
COSENTYX PEN ................ 39
COSENTYX PEN (2 PENS) 39
COSMEGEN ........................ 12
COSOPT ............................... 89
COSOPT (PF) ....................... 89
cosyntropin ........................... 51
COSYNTROPIN .................. 51
COTELLIC ........................... 12
COUMADIN ........................ 35
covaryx ................................. 81
covaryx h.s. ........................... 81
COZAAR .............................. 32
CREON................................. 71
CRESEMBA........................... 3
CRESTOR ............................ 37
CRESYLATE ....................... 50
CRINONE ............................ 81
CRIXIVAN ............................ 3
cromolyn................... 71, 88, 93
cryselle (28) .......................... 84
CUPRIMINE ........................ 80
CUROSURF ......................... 93
CUTIVATE .......................... 46
CUVPOSA ........................... 69
cyanocobalamin (vitamin b-12)
.......................................... 99
cyclafem 1/35 (28) ............... 84
cyclafem 7/7/7 (28) .............. 84
CYCLESSA (28) .................. 84
cyclobenzaprine .................... 20
CYCLOGYL ........................ 88
CYCLOMYDRIL................. 90
cyclopentolate....................... 88
cyclophosphamide ................ 12
CYCLOSERINE .................... 7
CYCLOSET ......................... 67
cyclosporine ................... 12, 13
cyclosporine modified .......... 13
CYKLOKAPRON................ 35
CYMBALTA ....................... 26
cyproheptadine ..................... 90
CYRAMZA .......................... 13
cyred ..................................... 84
CYSTADANE...................... 71
CYSTAGON ........................ 95
CYSTARAN ........................ 88
cytarabine ............................. 13
cytarabine (pf) ...................... 13
CYTOMEL........................... 69
CYTOTEC ........................... 74
CYTOVENE .......................... 3
cytra k crystals ...................... 95
cytra-2................................... 95
cytra-3................................... 95
cytra-k................................... 95
D
D.H.E.45............................... 19
dacarbazine ........................... 13
DACOGEN .......................... 13
DAKLINZA ........................... 3
DALIRESP ........................... 93
DALVANCE .......................... 7
danazol ................................. 66
DANTRIUM ........................ 20
dantrolene ............................. 20
dapsone ................................... 7
DAPTACEL (DTAP
PEDIATRIC) (PF) ............ 77
DARAPRIM ........................... 7
darifenacin ............................ 95
DARZALEX ........................ 13
dasetta 1/35 (28) ................... 84
dasetta 7/7/7 (28) .................. 84
daunorubicin ......................... 13
DAYPRO.............................. 24
daysee ................................... 84
DAYTRANA........................ 26
DDAVP ................................ 66
DEBACTEROL.................... 49
deblitane ............................... 81
decitabine.............................. 13
DELESTROGEN ................. 81
deltasone ............................... 51
delyla (28)............................. 84
DELZICOL .......................... 71
DEMADEX .......................... 32
demeclocycline ..................... 10
DEMEROL........................... 21
demerol (pf) .......................... 21
DEMEROL (PF)................... 21
DEMSER .............................. 32
DENAVIR ............................ 45
denta 5000 plus ..................... 49
dentagel ................................ 49
DEPACON ........................... 16
DEPAKENE ......................... 16
DEPAKOTE ......................... 16
DEPAKOTE ER ................... 16
DEPAKOTE SPRINKLES .. 16
DEPEN TITRATABS .......... 80
DEPO-ESTRADIOL ............ 81
DEPO-PROVERA................ 81
DEPO-SUBQ PROVERA 104
.......................................... 81
DEPO-TESTOSTERONE .... 66
DERMAPAK PLUS ............. 42
DERMA-SMOOTHE/FS
BODY OIL ....................... 46
DERMA-SMOOTHE/FS
SCALP OIL ...................... 46
DERMASORB HC
COMPLETE KIT ............. 46
DERMASORB TA
COMPLETE KIT ............. 46
DERMASORB XM
COMPLETE KIT ............. 40
DERMATOP ........................ 46
DERMOTIC OIL.................. 50
DESCOVY .............................3
desipramine........................... 26
desloratadine ......................... 90
desmopressin ........................ 66
desog-e.estradiol/e.estradiol . 84
DESOGEN ........................... 84
desogestrel-ethinyl estradiol . 84
DESONATE ......................... 46
desonide ................................ 46
DESOWEN........................... 46
desoximetasone..................... 46
DESOXYN ........................... 26
DESVENLAFAXINE .......... 26
DESVENLAFAXINE
FUMARATE .................... 26
DETROL .............................. 95
DETROL LA ........................ 95
dexamethasone ..................... 51
dexamethasone intensol ........ 51
dexamethasone sodium
phosphate .......................... 90
dexedrine .............................. 26
DEXEDRINE SPANSULE ..26
dexferrum .............................99
DEXILANT ..........................74
dexmethylphenidate ..............26
DEXPAK 10 DAY ...............51
DEXPAK 13 DAY ...............51
DEXPAK 6 DAY .................51
dexrazoxane hcl ....................11
dextroamphetamine ..............26
dextroamphetamineamphetamine.....................26
dialyvite ................................99
DIALYVITE 3000................99
DIALYVITE 5000................99
dialyvite 800 .........................99
DIALYVITE 800 WITH IRON
..........................................99
DIALYVITE SUPREME D .99
DIAMOX SEQUELS ........... 89
DIASTAT .............................16
DIASTAT ACUDIAL .......... 16
115
DIATRUE PLUS BLOOD
GLUCOSE MET .............. 57
DIATRUE PLUS TEST STRIP
.......................................... 52
diazepam......................... 16, 26
diazepam intensol ................. 26
DIBENZYLINE ................... 32
DICLEGIS ............................ 71
diclofenac potassium ............ 24
diclofenac sodium .... 24, 40, 89
diclofenac-misoprostol ......... 24
dicloxacillin ............................ 9
dicyclomine .......................... 69
didanosine............................... 4
DIFFERIN ............................ 42
DIFICID ................................. 6
difil-g 400 ............................. 93
diflorasone ............................ 46
DIFLUCAN............................ 3
diflunisal ............................... 24
DIGEX NF ........................... 71
digitek ................................... 34
digox ..................................... 35
digoxin.................................. 35
dihydrocode-acetaminophencaff .................................... 21
dihydrocodeine-aspirin-caff . 21
dihydroergotamine ............... 19
DILACOR XR...................... 32
DILANTIN ........................... 16
DILANTIN EXTENDED .... 16
DILANTIN INFATABS ...... 17
DILANTIN-125 ................... 17
DILATRATE-SR ................. 38
DILAUDID .......................... 21
DILAUDID-HP (PF) ............ 21
diltiazem ............................... 32
dimenhydrinate ..................... 71
DIOVAN .............................. 32
DIOVAN HCT ..................... 32
DIPENTUM ......................... 71
diphenhydramine hcl ............ 90
diphenoxylate-atropine ......... 69
DIPROLENE........................ 46
DIPROLENE AF.................. 46
dipyridamole......................... 35
DISALCID ........................... 24
diskets ................................... 22
disopyramide phosphate ....... 30
disulfiram.............................. 48
DITROPAN XL ................... 95
DIURIL ................................ 32
DIURIL IV ........................... 32
divalproex ............................. 17
DIVIGEL .............................. 81
DOCEFREZ ......................... 13
docetaxel ............................... 13
dologesic (wphenyltoloxamine) ............ 24
DOLOPHINE ....................... 22
donepezil .............................. 20
DONNATAL ........................ 69
DONNATAL EXTENTABS 69
DORAL ................................ 26
DORIBAX .............................. 7
DORYX ................................ 10
DORYX MPC ...................... 10
dorzolamide .......................... 89
dorzolamide-timolol ............. 89
dothelle dha .......................... 99
DOVONEX .......................... 39
doxazosin .............................. 32
doxepin ........................... 26, 40
doxercalciferol ...................... 66
DOXIL.................................. 13
doxorubicin........................... 13
doxorubicin, peg-liposomal .. 13
doxy-100 ............................... 10
doxycycline hyclate .............. 10
doxycycline monohydrate ... 10,
11
DOXYCYCLINE
MONOHYDRATE ........... 10
doxytex ................................. 90
DRISDOL............................. 99
drithocreme hp ...................... 39
dronabinol ............................. 71
droperidol ............................. 71
DROPLET LANCETS ......... 57
DROPLET LANCING
DEVICE ........................... 57
DROPLET PEN NEEDLE ... 57
drospirenone-ethinyl estradiol
.......................................... 84
DROXIA .............................. 13
DUAC ................................... 42
DUAVEE.............................. 81
DUET DHA BALANCED ... 99
116
DUET DHA EC-OM 3 ......... 99
DUET DHA WITH OMEGA-3
.......................................... 99
DUETACT ........................... 67
DUEXIS ............................... 24
DULERA .............................. 93
duloxetine ............................. 26
DUODOTE ........................... 47
DUOPA ................................ 18
DURACHOL ........................ 99
DURAGESIC ....................... 22
duramorph (pf)...................... 22
DUREZOL ........................... 90
DURLAZA ........................... 35
dutasteride............................. 95
dutasteride-tamsulosin .......... 95
DUTOPROL ......................... 32
DYANAVEL XR ................. 26
DYAZIDE ............................ 32
DYLOJECT .......................... 24
DYMISTA ............................ 93
DYRENIUM......................... 32
DYSPORT ............................ 77
dytuss .................................... 90
E
e.e.s. 400 ................................. 6
E.E.S. GRANULES ................ 6
EASY CLICK LANCING
DEVICE ........................... 57
EASY COMFORT LANCETS
.......................................... 57
EASY COMFORT PEN
NEEDLES ........................ 57
EASY MINI EJECT
EASY PLUS II BLOOD
GLUCOSE MET .............. 57
EASY PLUS II TEST ........... 52
EASY STEP ......................... 52
EASY STEP BLOOD
GLUCOSE METER ......... 57
EASY TALK BLOOD
EASY TALK GLUCOSE
TEST................................. 52
EASY TOUCH FLIPLOCK
NEEDLE........................... 57
EASY TOUCH GLUCOSE
MONITOR ....................... 57
EASY TOUCH
HYPODERMIC NEEDLE
.......................................... 57
EASY TOUCH LANCING
DEVICE ........................... 57
EASY TOUCH TEST STRIP
.......................................... 52
EASY TRAK BLOOD
EASY TRAK GLUCOSE
TEST ................................ 52
EASYGLUCO
MONITORING SYSTEM 57
EASYGLUCO PLUS ........... 52
EASYGLUCO TEST ........... 52
EASYMAX .......................... 52
EASYMAX L BLOOD
EASYMAX NG ................... 57
EASYMAX V SPEAKING
GLUCOSE SYS ............... 57
EASYMAX V2 BLOOD
EC-NAPROSYN .................. 24
econazole .............................. 44
econtra ez.............................. 84
ECOZA................................. 44
EDARBI ............................... 32
EDARBYCLOR ................... 32
EDECRIN............................. 32
EDLUAR .............................. 26
ed-spaz .................................. 69
EDURANT ............................. 4
eemt ...................................... 81
eemt hs.................................. 81
effer-k ................................... 96
EFFER-K.............................. 96
EFFEXOR XR...................... 26
EFFIENT .............................. 35
EFUDEX .............................. 40
EGRIFTA ............................. 75
ELAPRASE.......................... 66
ELDEPRYL ......................... 18
ELDERCAPS ....................... 99
ELELYSO ............................ 66
ELEMENT COMPACT
ELEMENT COMPACT TEST
STRIPS ............................. 52
ELEMENT COMPACT V
GLUCOSE MTR .............. 58
ELEMENT PLUS BLOOD
GLUCOSE KIT ................ 58
ELEMENT TEST STRIPS... 52
ELESTAT ............................. 88
ELESTRIN ........................... 81
eletone .................................. 40
ELIDEL ................................ 40
ELIGARD ............................ 13
ELIMITE .............................. 47
elinest.................................... 84
eliphos .................................. 71
ELIQUIS .............................. 35
ELITEK ................................ 11
elite-ob .................................. 99
ELIXOPHYLLIN ................. 93
ELLA .................................... 84
ELLENCE ............................ 13
ELMIRON ............................ 95
ELOCON .............................. 46
ELOCTATE ......................... 35
EMADINE............................ 88
EMBEDA ............................. 22
EMBRACE BLOOD
GLUCOSE SYSTEM . 52, 58
EMBRACE EVO TEST
STRIPS ............................. 52
EMBRACE PRO GLUCOSE
METER ............................ 58
EMBRACE PRO TEST
STRIPS ............................. 52
EMCYT ................................ 13
EMEND ................................ 71
emoquette ............................. 84
EMPLICITI .......................... 13
EMSAM ............................... 26
EMTRIVA .............................. 4
emulsion sb ........................... 40
EMVERM .............................. 7
ENABLEX ........................... 95
enalapril maleate................... 32
enalaprilat ............................. 32
enalapril-hydrochlorothiazide
.......................................... 32
ENBREL .............................. 80
ENBREL SURECLICK ....... 80
endocet.................................. 22
ENDOMETRIN.................... 81
ENGERIX-B (PF) ................ 77
ENGERIX-B PEDIATRIC
(PF) ................................... 77
ENJUVIA ............................. 81
ENLITE SYSTEM ............... 58
ENLYTE (FERROUS
GLYCINE) ....................... 99
enoxaparin ............................ 35
enpresse ................................ 84
enskyce ................................. 84
ENSTILAR ........................... 39
entacapone ............................ 18
entecavir ................................. 4
ENTOCORT EC ................... 71
ENTRESTO .......................... 38
ENTYVIO ............................ 71
enulose ..................................71
ENVARSUS XR .................. 13
EPANED .............................. 32
EPCLUSA .............................. 4
EPICERAM .......................... 40
EPIDUO ............................... 42
EPIDUO FORTE .................. 42
EPIFOAM............................. 39
epinastine .............................. 88
epinephrine ........................... 91
EPIPEN 2-PAK .................... 91
EPIPEN JR 2-PAK ............... 91
epirubicin .............................. 13
EPISIL .................................. 49
EPISNAP .............................. 91
epitol ..................................... 17
EPIVIR ................................... 4
EPIVIR HBV .......................... 4
eplerenone............................. 32
EPOGEN .............................. 75
epoprostenol (glycine) ..........32
eprosartan .............................32
EPZICOM...............................4
EQUETRO ........................... 17
ERAXIS(WATER DILUENT)
............................................ 3
ERBITUX ............................. 13
ergocalciferol (vitamin d2) ... 99
ergoloid ................................. 26
ERGOMAR .......................... 19
ERIVEDGE .......................... 13
errin....................................... 82
ERTACZO ............................ 44
117
ERWINAZE ......................... 13
ery pads ................................ 42
erygel .................................... 42
ERYPED 200 ......................... 6
ERYPED 400 ......................... 6
ery-tab..................................... 6
ERY-TAB............................... 6
ERYTHROCIN ...................... 6
erythrocin (as stearate) ........... 6
erythromycin .................... 6, 87
erythromycin ethylsuccinate .. 6
erythromycin with ethanol ... 43
erythromycin-benzoyl peroxide
.......................................... 43
ESBRIET.............................. 93
ESCAVITE........................... 99
ESCAVITE D....................... 99
ESCAVITE LQ .................... 99
escitalopram oxalate ............. 26
ESGIC .................................. 22
esmolol ................................. 32
esomeprazole magnesium .... 74
esomeprazole sodium ........... 74
ESOMEPRAZOLE
STRONTIUM................... 74
estarylla ................................ 84
estazolam .............................. 27
ESTRACE ............................ 82
estradiol ................................ 82
estradiol valerate .................. 82
estradiol-norethindrone acet . 82
ESTRING ............................. 82
ESTROGEL ......................... 82
estrogens-methyltestosterone82
estropipate ............................ 82
ESTROSTEP FE-28 ............. 84
eszopiclone ........................... 27
ethacrynate sodium ............... 32
ethambutol .............................. 7
ethosuximide ........................ 17
ethyl chloride ........................ 44
etidronate disodium .............. 48
etodolac ................................ 24
ETOPOPHOS ....................... 13
etoposide............................... 13
EURAX ................................ 47
EVAMIST ............................ 82
EVEKEO .............................. 27
EVENCARE G2............. 52, 58
EVENCARE G3 GLUCOSE
METER ............................ 58
EVENCARE G3 TEST ........ 52
EVENCARE MINI
GLUCOSE TEST STR..... 52
EVISTA ................................ 80
EVOCLIN ............................ 43
EVOLUTION BLOOD
EVOLUTION TEST STRIPS
.......................................... 52
EVOMELA .......................... 13
EVOTAZ ................................ 4
EVOXAC ............................. 48
EVZIO .................................. 24
EXALGO ER ....................... 22
EXEL HYPODERMIC
NEEDLES ........................ 58
EXELDERM ........................ 44
EXELON .............................. 20
exemestane ........................... 13
EXFORGE............................ 32
EXFORGE HCT................... 32
EXJADE ............................... 48
EXODERM .......................... 45
exotic-hc ............................... 50
EXPECTA PRENATAL ...... 99
EXTAVIA ............................ 75
EXTINA ............................... 45
EXTRA-VIRT PLUS DHA.. 99
EYLEA ................................. 88
EZ FLU 2015-16 (FLUVIRIN)
(PF) ................................... 77
EZ FLU 201516(FLUCELVAX)(PF) .... 77
e-z ject lancets ...................... 58
EZ SMART LANCETS ....... 58
EZ SMART PLUS SYSTEM
.......................................... 58
EZ SMART PLUS TEST ..... 52
EZ SMART SYSTEM.......... 58
EZ SMART TEST ................ 52
F
FA-8...................................... 99
fabb ....................................... 99
FABIOR ............................... 43
FABRAZYME ..................... 66
FACTIVE ............................. 10
fallback solo ......................... 84
118
falmina (28) ..........................84
famciclovir ..............................4
famotidine .............................74
famotidine (pf) ......................74
famotidine (pf)-nacl (iso-os) 74
FAMVIR.................................4
FANAPT............................... 27
FARESTON ......................... 13
FARXIGA ............................ 67
FARYDAK ........................... 13
FASLODEX ......................... 13
FAZACLO ............................ 27
FC2 FEMALE CONDOM ... 81
fe c plus................................. 99
FEIBA NF ............................ 35
felbamate .............................. 17
FELBATOL .......................... 17
FELDENE ............................ 24
felodipine .............................. 32
fem ph ................................... 83
FEMARA ............................. 13
FEMCAP .............................. 81
FEMCON FE ........................ 84
FEMHRT LOW DOSE ........82
FEMRING ............................ 82
fenofibrate............................. 37
FENOFIBRATE ................... 37
fenofibrate micronized..........37
fenofibrate nanocrystallized .37
fenofibric acid .......................37
fenofibric acid (choline) .......37
FENOGLIDE ........................37
fenoprofen.............................24
fentanyl .................................22
FENTANYL .........................22
fentanyl citrate ......................22
fentanyl citrate (pf) ...............22
FENTORA ............................22
FERAHEME.........................99
FERIVA 21-7 TABLET ....... 99
FERIVA FA (SUMALATE) 99
ferocon ..................................99
FERRALET 90 DUAL-IRON
DELIVERY ......................99
ferraplus 90 ...........................99
ferrex 150 forte .....................99
ferrex 150 forte plus .............99
ferrex 28................................99
FERRIPROX ........................48
FERRLECIT......................... 48
ferrocite plus ......................... 99
ferrogels forte ....................... 99
FETZIMA............................. 27
FEXMID............................... 20
FIBRICOR ........................... 37
FIFTY50 SAFETY SEAL
LANCETS ........................ 58
FIFTY50 TEST STRIP ........ 52
FINACEA............................. 43
FINACEA PLUS .................. 43
finasteride ............................. 95
FINE 30 UNIVERSAL
LANCETS ........................ 58
FINGERSTIX LANCETS ... 58
FIORICET ............................ 22
FIORICET WITH CODEINE
.......................................... 22
FIORINAL ........................... 22
FIORINAL-CODEINE #3 ... 22
FIRAZYR ............................. 93
FIRMAGON KIT W
DILUENT SYRINGE ...... 13
FIRST CHOICE LANCETS
THIN ................................ 58
FIRST-BXN ......................... 49
FIRST-DUKE'S.................... 49
FIRST-HYDROCORTISONE
.......................................... 46
FIRST-LANSOPRAZOLE .. 74
FIRST-MARY'S
MOUTHWASH ............... 49
FIRST-MOUTHWASH BLM
.......................................... 49
FIRST-OMEPRAZOLE ....... 74
FIRST-PROGESTERONE
VGS 100 ........................... 82
FIRST-PROGESTERONE
VGS 200 ........................... 82
FIRST-PROGESTERONE
VGS 25 ............................. 82
FIRST-PROGESTERONE
VGS 400 ........................... 82
FIRST-PROGESTERONE
VGS 50 ............................. 82
FIRST-TESTOSTERONE ... 66
FIRST-TESTOSTERONE MC
.......................................... 66
FLAGYL ................................ 7
FLAGYL ER .......................... 7
FLAREX .............................. 90
flavoxate ............................... 95
FLEBOGAMMA DIF .......... 77
flecainide .............................. 30
FLECTOR ............................ 24
FLOLAN .............................. 32
FLOMAX ............................. 95
FLORIVA ............................. 99
FLORIVA (FLUORIDEVITAMIN D3) ................. 99
FLORIVA PLUS .................. 99
FLOVENT DISKUS ............ 93
FLOVENT HFA ................... 93
FLOW-EZE VENTED
NEEDLE .......................... 58
FLOWTUSS ......................... 91
floxuridine ............................ 13
FLUARIX 2012-2013 (PF) .. 77
FLUARIX 2013-2014 (PF) .. 77
FLUARIX 2014-2015 (PF) .. 77
FLUARIX QUAD 2013-2014
(PF) ................................... 77
(PF) ................................... 77
(PF) ................................... 77
(PF) ................................... 77
FLUBLOK 2013-2014 (PF) . 77
FLUBLOK 2014-2015 (PF) . 77
FLUBLOK 2015-2016 (PF) . 77
flucaine ................................. 88
FLUCELVAX (PF) .............. 77
FLUCELVAX 2013-2014 (PF)
.......................................... 77
.......................................... 77
.......................................... 77
fluconazole ............................. 3
fluconazole in dextrose(iso-o) 3
flucytosine .............................. 3
fludarabine ............................ 13
fludrocortisone...................... 51
FLULAVAL 2012-2013....... 77
FLULAVAL 2013-2014....... 77
FLULAVAL 2014-2015....... 77
FLULAVAL QUAD 20132014 .................................. 77
FLULAVAL QUAD 20142015 .................................. 77
FLULAVAL QUAD 20142015 (PF) .......................... 77
FLULAVAL QUAD 20152016 .................................. 77
FLULAVAL QUAD 20162017 .................................. 77
FLUMADINE......................... 4
flumazenil ............................. 27
FLUMIST 2012-2013 ........... 77
FLUMIST 2013-2014 ........... 77
FLUMIST QUAD 2014-2015
.......................................... 77
FLUMIST QUAD 2015-2016
.......................................... 77
flunisolide ............................. 93
fluocinolone .......................... 46
fluocinolone acetonide oil .... 50
fluocinolone and shower cap 46
fluocinonide .......................... 46
fluocinonide-e ....................... 46
FLUORABON ...................... 99
FLUOR-A-DAY ................... 99
fluor-a-day (with xylitol) .... 100
fluorescein-benoxinate ......... 88
fluorescein-proparacaine ...... 88
fluoridex daily defense ......... 49
FLUORIDEX SENSITIVITY
RELIEF............................. 49
fluoritab .............................. 100
FLUORITAB ...................... 100
fluorometholone ................... 90
FLUOROPLEX .................... 40
fluorouracil ..................... 13, 40
FLUOROURACIL ............... 40
fluoxetine .............................. 27
FLUOXETINE ..................... 27
fluphenazine decanoate ........ 27
fluphenazine hcl.................... 27
FLURA-DROPS ................. 100
flurandrenolide ..................... 46
flurazepam ............................ 27
flurbiprofen ........................... 24
flurbiprofen sodium ..............89
flurox ....................................88
flutamide ...............................13
119
fluticasone ...................... 46, 93
fluvastatin ............................. 37
FLUVIRIN 2012-2013 ......... 77
FLUVIRIN 2012-2013 (PF) . 78
FLUVIRIN 2013-2014 ......... 78
FLUVIRIN 2013-2014 (PF) . 78
FLUVIRIN 2014-2015 ......... 78
FLUVIRIN 2014-2015 (PF) . 78
FLUVIRIN 2015-2016 ......... 78
FLUVIRIN 2015-2016 (PF) . 78
fluvoxamine.......................... 27
FLUZONE 2012-2013 ......... 78
FLUZONE 2012-2013 (PF) . 78
FLUZONE 2013-2014 ......... 78
FLUZONE 2013-2014 (PF) . 78
FLUZONE 2014-2015 ......... 78
FLUZONE 2014-2015 (PF) . 78
FLUZONE 2015-2016 ......... 78
FLUZONE HIGH-DOSE
2012-13 (PF) .................... 78
FLUZONE HIGH-DOSE
2013-14 (PF) .................... 78
FLUZONE HIGH-DOSE
2014-15 (PF) .................... 78
FLUZONE HIGH-DOSE
2015-16 (PF) .................... 78
FLUZONE HIGH-DOSE
2016-17 (PF) .................... 78
FLUZONE INTRADERM
2012-13 (PF) .................... 78
FLUZONE INTRADERM
2013-14 (PF) .................... 78
FLUZONE INTRADERM
2014-15 (PF) .................... 78
FLUZONE INTRADERM
QUAD 2015-16 ................ 78
FLUZONE INTRADERM
QUAD 2016-17 ................ 78
FLUZONE PEDI 2012 -2013
(PF) ................................... 78
FLUZONE PEDI 2013-2014
(PF) ................................... 78
FLUZONE QUAD 2013-2014
(PF) ................................... 78
.......................................... 78
(PF) ................................... 78
.......................................... 78
(PF) ................................... 78
.......................................... 78
(PF) ................................... 78
FLUZONE QUAD PEDI
2013-14 (PF)..................... 78
FLUZONE QUAD PEDI
2014-15 (PF)..................... 78
FLUZONE QUAD PEDI
2015-16 (PF)..................... 78
FLUZONE QUAD PEDI
2016-17 (PF)..................... 79
FML FORTE ........................ 90
FML LIQUIFILM ................ 90
FML S.O.P. .......................... 90
focalgin 90 dha ................... 100
focalgin ca .......................... 100
focalgin dss ......................... 100
FOCALIN ............................. 27
FOCALIN XR ...................... 27
folbecal ............................... 100
folbee .................................. 100
folbee ar .............................. 100
folbee plus .......................... 100
FOLET DHA ...................... 100
FOLET ONE ...................... 100
FOLGARD OS ................... 100
FOLGARD RX................... 100
folic acid ............................. 100
folic acid-vit b6-vit b12 ...... 100
folivane-f ............................ 100
folivane-ob.......................... 100
folivane-plus ....................... 100
FOLLISTIM AQ .................. 66
FOLOTYN ........................... 13
folplex 2.2........................... 100
foltabs 800 .......................... 100
FOLTRATE........................ 100
fondaparinux ......................... 35
FORA D10 ........................... 52
FORA D15G......................... 52
FORA D20 ..................... 52, 58
FORA D40-G31 TEST
STRIPS ............................. 52
FORA G20 ..................... 53, 58
120
FORA G30A ................... 53, 58
FORA GD50 BLOOD
GLUCOSE SYSTEM ....... 58
FORA GD50 TEST STRIPS 53
FORA LANCING DEVICE . 58
FORA TEST N'GO VOICE
METER............................. 58
FORA TEST STRIP ............. 53
FORA TN'G VOICE METER
.......................................... 58
FORA TN'G VOICE TEST
STRIPS ............................. 53
FORA V10...................... 53, 58
FORA V10-V12-D10-D20 ... 58
FORA V12 BLOOD
FORA V12 GLUCOSE ........ 53
FORA V20...................... 53, 58
FORA V30A ......................... 58
FORACARE GD20 ..............53
FORACARE GD20
FORACARE GD40 .............. 53
FORACARE GD40A
FORACARE GD40B
FORACARE LANCETS ...... 58
FORADIL AEROLIZER......93
FORFIVO XL .......................27
FORTAMET.........................67
FORTAVIT .......................... 98
FORTAZ................................. 6
FORTAZ IN DEXTROSE 5 %
............................................ 6
FORTEO............................... 80
FORTESTA .......................... 66
fortical................................... 66
FORTISCARE BLOOD
GLUCOSE SYST ............. 59
FORTISCARE GLUCOSE
TEST STRIPS .................. 53
FOSAMAX........................... 80
FOSAMAX PLUS D ............ 80
foscarnet ................................. 4
FOSCAVIR ............................ 4
fosinopril............................... 32
fosinopril-hydrochlorothiazide
.......................................... 32
fosphenytoin ......................... 17
FOSRENOL ......................... 71
FRAGMIN ........................... 35
FREESTYLE FLASH
SYSTEM .......................... 59
FREESTYLE FREEDOM ... 59
FREESTYLE FREEDOM
LITE ................................. 59
FREESTYLE INSULINX ... 53,
59
FREESTYLE INSULINX
TEST STRIPS .................. 53
FREESTYLE LANCETS..... 59
FREESTYLE LITE METER 59
FREESTYLE LITE STRIPS 53
FREESTYLE PRECISION
NEO METER ................... 59
FREESTYLE PRECISION
NEO STRIPS.................... 53
FREESTYLE SIDEKICK II 59
FREESTYLE SYSTEM KIT59
FREESTYLE TEST ............. 53
FREESTYLE UNISTIK 2.... 59
FROVA ................................ 19
frovatriptan ........................... 19
full spectrum b-vitamin c ... 100
FULYZAQ ........................... 69
FURADANTIN .................... 11
furosemide ............................ 32
FUSION PLUS ................... 100
FUZEON ................................ 4
fyavolv.................................. 82
FYCOMPA .......................... 17
G
G-4 TEST ............................. 53
gabapentin ............................ 17
GABITRIL ........................... 17
galantamine .......................... 20
GALZIN ............................... 96
ganciclovir sodium ................. 4
GANIRELIX ........................ 66
GARDASIL (PF).................. 79
GARDASIL 9 (PF)............... 79
gastrinex nf ........................... 71
GASTROCROM .................. 71
gatifloxacin ........................... 87
GATTEX 30-VIAL .............. 71
gavilyte-c .............................. 71
gavilyte-g .............................. 71
gavilyte-h and bisacodyl ....... 71
gavilyte-n .............................. 71
GAZYVA ............................. 13
GE100 BLOOD GLUCOSE
SYSTEM .......................... 59
GE100 BLOOD GLUCOSE
TEST STRIP..................... 53
GELCLAIR .......................... 49
GELNIQUE .......................... 95
GELX ................................... 50
gemcitabine .......................... 13
gemfibrozil ........................... 37
GEMZAR ............................. 13
GENERESS FE .................... 84
generlac ................................ 71
gengraf .................................. 13
GENOTROPIN .................... 75
GENOTROPIN MINIQUICK
.......................................... 75
GENSTRIP TEST STRIP .... 53
gentak ................................... 87
gentamicin .................. 7, 44, 87
gentamicin in nacl (iso-osm) .. 7
GENTAMICIN IN NACL
(ISO-OSM) ......................... 8
gentamicin sulfate (ped) (pf) .. 8
gentamicin sulfate (pf)............ 8
GENTAMICIN SULFATE
(PF) ..................................... 8
GENTEX 30 ......................... 91
GENVOYA ............................ 4
GEODON ............................. 27
gianvi (28) ............................ 84
GIAZO.................................. 71
gildagia ................................. 84
gildess 1.5/30 (21) ................ 84
gildess 1/20 (21) ................... 84
gildess 24 fe .......................... 84
gildess fe 1.5/30 (28) ............ 84
gildess fe 1/20 (28) ............... 84
GILENYA ............................ 75
GILOTRIF ............................ 13
GLASSIA ............................. 48
glatopa .................................. 75
GLEEVEC ............................ 13
GLEOSTINE ........................ 13
GLIADEL WAFER .............. 13
glimepiride............................ 67
glipizide ................................ 68
glipizide-metformin .............. 68
GLUCAGEN DIAGNOSTIC
KIT ................................... 54
GLUCAGEN HYPOKIT...... 54
GLUCAGON EMERGENCY
KIT (HUMAN) ................. 55
GLUCAGON HCL ............... 54
GLUCO NAVII GLUCOSE
MONITOR ....................... 59
GLUCO NAVII TEST STRIP
.......................................... 53
GLUCOCARD 01 METER .. 59
GLUCOCARD 01 SENSOR
PLUS ................................ 53
GLUCOCARD EXPRESSION
.................................... 53, 59
GLUCOCARD SHINE
METER............................. 59
GLUCOCARD SHINE TEST
STRIPS ............................. 53
GLUCOCARD VITAL ........ 59
GLUCOCARD VITAL
SENSOR ........................... 53
GLUCOCARD VITAL TEST
STRIPS ............................. 53
GLUCOCOM BLOOD
GLUCOSE ........................ 59
GLUCOCOM GLUCOSE .... 53
GLUCOCOM LANCETS .... 59
GLUCOPHAGE ................... 68
GLUCOPHAGE XR ............ 68
GLUCOTROL ...................... 68
GLUCOTROL XL................ 68
GLUCOVANCE................... 68
glyburide ............................... 68
glyburide micronized ............ 68
glyburide-metformin............. 68
GLYCATE ........................... 69
GLYCOPHOS ...................... 96
glycopyrrolate ....................... 69
glydo ..................................... 44
GLYNASE ........................... 68
GLYSET ............................... 68
GLYXAMBI......................... 68
GM100 ............................ 53, 59
GMATE LANCETS ............. 59
GMATE LANCING DEVICE
.......................................... 59
GMATE SMART METER... 59
121
GMATE SMART STARTER
.......................................... 59
GMATE TEST STRIPS ....... 53
GMATE VOICE METER .... 59
GOLYTELY......................... 71
GONAL-F ............................ 66
GONAL-F RFF .................... 66
GONAL-F RFF REDI-JECT 66
GORDONS UREA............... 40
GRALISE ............................. 17
GRALISE 30-DAY STARTER
PACK ............................... 17
granisetron (pf) ..................... 71
granisetron hcl ...................... 71
granisol ................................. 71
GRANIX .............................. 75
GRASTEK ........................... 79
griseofulvin microsize ............ 3
griseofulvin ultramicrosize..... 3
GRIS-PEG
(ULTRAMICROSIZE) ...... 3
guaifenesin ac ....................... 91
guaifenesin dac ..................... 91
guanfacine ...................... 27, 32
guanidine .............................. 27
GYNAZOLE-1 ..................... 83
H
HALAVEN........................... 13
HALCION ............................ 27
HALDOL ............................. 27
HALDOL DECANOATE .... 27
halobetasol propionate.......... 46
HALOG ................................ 46
haloperidol ............................ 27
haloperidol decanoate ........... 27
haloperidol lactate ................ 27
HARVONI ............................. 4
HAVRIX (PF) ...................... 79
HEALTHPRO GLUCOSE
MONITOR ....................... 59
HEALTHPRO TEST STRIPS
.......................................... 53
HEALTHY ACCENTS
AUTOLET ....................... 59
HEALTHY ACCENTS
UNIFINE PENTIP ........... 59
HEALTHY ACCENTS
UNILET LANCET........... 59
heartburn treatment 24 hour . 74
heather .................................. 82
HECTOROL......................... 66
HELIDAC ............................ 74
HELIXATE FS ..................... 35
HEMANGEOL..................... 32
hematinic plus vit/minerals 100
hematinic/folic acid ............ 100
hematogen .......................... 100
hematogen fa ...................... 100
hematogen forte .................. 100
HEMATRON ..................... 100
HEMATRON-AF ............... 100
HEMAX ............................. 100
hemenatal ob....................... 100
hemenatal ob + dha ............ 100
hemetab .............................. 100
hemmorex-hc ........................ 71
HEMOCYTE-F .................. 100
HEMOCYTE-PLUS ........... 100
HEMOFIL M HIGH ............. 35
HEMOFIL M LOW.............. 35
HEMOFIL M MID ............... 35
HEMOFIL M SUPER HIGH35
hep flush-10 (pf) ................... 35
HEPAGAM B....................... 79
heparin (porcine) .................. 35
heparin (porcine) in 5 % dex 35
heparin (porcine) in nacl (pf) 35
heparin flush ......................... 36
heparin flush(porcine)-0.9nacl
.......................................... 36
heparin lock flush ................. 36
heparin lock flush (porcine) . 36
heparin lockflush(porcine)(pf)
.......................................... 36
heparin(porcine) in 0.45% nacl
.......................................... 36
HEPARIN(PORCINE) IN
0.45% NACL .................... 36
heparin, porcine (pf) ............. 36
HEPSERA .............................. 4
HERCEPTIN ........................ 13
HETLIOZ ............................. 27
HEXALEN ........................... 13
HIPREX................................ 11
HISTEX-AC ......................... 91
HIZENTRA .......................... 79
homatropaire ......................... 88
homatropine hbr ................... 88
122
HORIZANT .......................... 20
hpr ......................................... 40
hpr plus ................................. 40
hpr plus hydrogel .................. 40
HPR PLUS-MB HYDROGEL
.......................................... 40
huber safety needles (disp.) .. 59
HUMALOG .......................... 65
HUMALOG KWIKPEN ......65
HUMALOG MIX 50-50....... 65
HUMALOG MIX 50-50
KWIKPEN ........................ 65
HUMALOG MIX 75-25....... 65
HUMALOG MIX 75-25
KWIKPEN ........................ 65
HUMAPEN LUXURA HD .. 59
HUMATE-P ......................... 36
HUMATROPE ..................... 75
HUMIRA .............................. 80
HUMIRA PEDIATRIC
CROHN'S START............ 80
HUMIRA PEN CROHN'SUC-HS START ................ 81
HUMULIN 70/30 ................. 65
HUMULIN 70/30 KWIKPEN
.......................................... 65
HUMULIN N ....................... 65
HUMULIN N KWIKPEN .... 65
HUMULIN R........................ 65
HUMULIN R U-500 (CONC)
KWIKPEN ........................ 65
HUMULIN R U-500
(CONCENTRATED) ....... 65
HYCAMTIN......................... 13
HYCET ................................. 22
HYCOFENIX ....................... 91
hydralazine ........................... 32
HYDREA ............................. 13
HYDRO 35 ........................... 40
HYDRO 40 ........................... 40
hydrochlorothiazide .............. 32
hydrocodone-acetaminophen 22
hydrocodone-chlorpheniramine
.......................................... 91
hydrocodone-cpmpseudoephed ..................... 91
hydrocodone-homatropine .... 91
hydrocodone-ibuprofen ........ 22
hydrocortisone .......... 46, 51, 71
hydrocortisone acetate .......... 71
hydrocortisone butyrate ........ 46
hydrocortisone butyr-emollient
.......................................... 46
hydrocortisone valerate ........ 46
hydrocortisone-acetic acid.... 50
hydrocortisone-min oil-wht pet
.......................................... 46
hydrocortisone-pramoxine .. 39,
71
hydromet............................... 91
hydromorphone .................... 22
HYDROMORPHONE ......... 22
hydromorphone (pf) ............. 22
hydroxocobalamin .............. 100
hydroxychloroquine ............... 8
hydroxyprogesterone caproate
.......................................... 82
hydroxyurea .......................... 13
hydroxyzine hcl .................... 91
hydroxyzine pamoate ........... 91
HYLENEX ........................... 48
hyolev mb ............................. 95
hyophen ................................ 95
hyoscyamine sulfate ............. 69
hyosyne................................. 69
HYPERHEP B S/D .............. 79
HYPERHEP B S-D
NEONATAL .................... 79
HYPERRAB S/D (PF) ......... 79
HYPER-SAL ........................ 93
HYPOLANCE AST
LANCING ........................ 59
HYSINGLA ER ................... 22
HYZAAR ............................. 32
I
ibandronate ........................... 80
IBRANCE ............................ 13
IBUDONE ............................ 22
ibuprofen .............................. 24
ibuprofen-oxycodone ........... 22
ic green ................................. 48
ICAR-C PLUS.................... 100
ICLUSIG .............................. 13
IDAMYCIN PFS .................. 13
idarubicin .............................. 13
iferex 150 forte ................... 100
IFEX ..................................... 13
ifosfamide ............................. 13
ifosfamide-mesna ................. 14
ILARIS (PF) ......................... 76
ILEVRO ............................... 89
ILOTYCIN ........................... 87
ILUVIEN .............................. 90
imatinib................................. 14
IMBRUVICA ....................... 14
imipenem-cilastatin ................ 8
imipramine hcl ...................... 27
imipramine pamoate ............. 27
imiquimod ............................ 76
IMITREX ............................. 19
IMITREX STATDOSE KIT
REFILL ............................ 19
IMITREX STATDOSE PEN19
IMLYGIC ............................. 14
IMOGAM RABIES-HT (PF)
.......................................... 79
IMPAVIDO ............................ 8
IMURAN .............................. 14
inatal advance ..................... 100
inatal gt ............................... 101
inatal ultra ........................... 101
INCIVEK................................ 4
INCONTROL LANCING
DEVICE ........................... 59
INCONTROL PEN NEEDLE
.......................................... 59
INCONTROL SUPER THIN
LANCETS ........................ 60
INCONTROL ULTRA THIN
LANCETS ........................ 60
INCRELEX .......................... 48
INCRUSE ELLIPTA ............ 93
indamix dm ........................... 91
indapamide ........................... 32
INDERAL LA ...................... 32
INDERAL XL ...................... 32
INDIOMIN MB .................... 95
INDOCIN ............................. 24
indocyanine green................. 48
indomethacin ........................ 24
INFANATE BALANCE .... 101
INFANRIX (DTAP) (PF)..... 79
INFASURF........................... 48
infed .................................... 101
INFERGEN .......................... 75
INFINITY STARTER KIT .. 60
INFINITY TEST STRIPS .... 53
INFUMORPH P/F ................ 22
INFUVITE ADULT ........... 101
INFUVITE PEDIATRIC .... 101
INJECT EASE LANCETS ... 60
INJECTAFER..................... 101
INLYTA ............................... 14
INNOPRAN XL ................... 32
INOVA ................................. 43
INOVA 4-1 ........................... 39
INOVA 8-2 ........................... 39
INSPRA ................................ 32
INSUPEN ............................. 60
INTEGRA F ....................... 101
INTEGRA PLUS ................ 101
INTELENCE .......................... 4
INTERMEZZO..................... 27
INTRON A ........................... 76
introvale ................................ 84
INTUNIV ER ....................... 27
INVACARE LANCETS ...... 60
INVANZ ................................. 8
INVEGA ............................... 27
INVEGA SUSTENNA ......... 27
INVEGA TRINZA ............... 27
INVIRASE ............................. 4
INVOKAMET ...................... 68
INVOKANA......................... 68
IODOPEN............................. 14
iophen c-nr ............................ 91
IOPIDINE ............................. 90
IPOL ..................................... 79
ipratropium bromide ....... 50, 93
ipratropium-albuterol ............93
irbesartan .............................. 32
irbesartan-hydrochlorothiazide
.......................................... 32
IRENKA ............................... 27
IRESSA ................................ 14
irinotecan .............................. 14
IRON .................................. 101
iron aspgly,ps-c-b12-fa-ca-suc
........................................ 101
IROSPAN 24/6 ................... 101
ISENTRESS ........................... 4
ISOCHRON .......................... 38
ISOLYTE S PH 7.4 .............. 98
ISOLYTE-S .......................... 98
isometh-dichloralacetaminophn .................... 19
123
isomethepten-cafacetaminophen .................. 19
isoniazid ................................. 8
ISOPTO ATROPINE ........... 88
ISOPTO CARPINE .............. 88
ISORDIL .............................. 38
ISORDIL TITRADOSE ....... 38
isosorbide dinitrate ............... 38
isosorbide mononitrate ......... 38
isoxsuprine ........................... 83
isradipine .............................. 32
ISTALOL ............................. 87
ISTODAX ............................ 14
itraconazole ............................ 3
ivermectin ............................... 8
IXEMPRA ............................ 14
J
JADENU .............................. 48
JAKAFI ................................ 14
JALYN ................................. 95
jantoven ................................ 36
JANUMET ........................... 68
JANUMET XR..................... 68
JANUVIA............................. 68
JARDIANCE........................ 68
jencycla................................. 82
JENTADUETO .................... 68
JENTADUETO XR.............. 68
JETREA (PF) ....................... 88
jevantique lo ......................... 82
JEVTANA ............................ 14
jinteli..................................... 82
jolessa ................................... 84
jolivette ................................. 82
JUBLIA ................................ 45
juleber ................................... 84
junel 1.5/30 (21) ................... 84
junel 1/20 (21) ...................... 84
junel fe 1.5/30 (28) ............... 84
junel fe 1/20 (28) .................. 84
junel fe 24 ............................. 84
JUXTAPID ........................... 37
K
KADCYLA .......................... 14
KADIAN .............................. 22
kaitlib fe................................ 84
KALBITOR .......................... 93
KALETRA ............................. 4
KALYDECO ........................ 93
kanamycin .............................. 8
KAPVAY ............................. 27
KARBINAL ER ................... 91
kariva (28) ............................ 84
KAYEXALATE ................... 71
KAZANO ............................. 68
KCENTRA ........................... 36
k-effervescent ....................... 96
KEFLEX ................................. 6
kelnor 1/35 (28) .................... 85
KENALOG ........................... 46
KEPIVANCE ....................... 11
KEPPRA............................... 17
KEPPRA XR ........................ 17
KERAFOAM........................ 40
KERALAC ........................... 40
KERALYT RX ..................... 40
KERALYT SCALP
COMPLETE ..................... 40
KERYDIN ............................ 45
KETEK ................................... 8
ketoconazole ..................... 3, 45
ketodan kit ............................ 45
ketoprofen ............................. 24
ketorolac ......................... 24, 89
KEVEYIS ............................. 20
KEYTRUDA ........................ 14
KHEDEZLA ......................... 27
kimidess (28) ........................ 85
KINERET ............................. 76
KINEVAC ............................ 71
KINNEY BRAND LANCETS
.......................................... 60
KINRIX (PF) ........................ 79
kionex ................................... 71
KITABIS PAK ....................... 8
KLARON ............................. 44
klofensaid ii .......................... 24
KLONOPIN.......................... 17
klor-con ................................ 96
klor-con 10 ........................... 97
klor-con 8 ............................. 97
klor-con m10 ........................ 97
klor-con m15 ........................ 97
klor-con m20 ........................ 97
klor-con sprinkle................... 97
KLOR-CON/25 .................... 97
klor-con/ef ............................ 97
KOATE-DVI ........................ 36
124
KOGENATE FS ................... 36
KOMBIGLYZE XR ............. 68
KORLYM ............................. 66
KOVALTRY ........................ 36
K-PHOS NO 2 ...................... 95
K-PHOS ORIGINAL ........... 96
k-phos-neutral ....................... 97
KRISTALOSE ...................... 71
KRYSTEXXA ...................... 80
k-sol ...................................... 97
k-tab ...................................... 97
K-TAB .................................. 97
kurvelo .................................. 85
KUVAN ................................ 66
KYNAMRO ......................... 37
KYPROLIS........................... 14
L
l norgest/e.estradiol-e.estrad . 85
labetalol ................................ 32
LACRISERT ........................ 88
lactated ringers...................... 47
lactic acid .............................. 40
lactic acid e ........................... 40
lactulose ................................ 71
LAMICTAL ......................... 17
LAMICTAL ODT ................ 17
LAMICTAL ODT STARTER
(BLUE) ............................. 17
(GREEN) .......................... 17
(ORANGE) ....................... 17
LAMICTAL STARTER
(BLUE) KIT ..................... 17
LAMICTAL STARTER
(GREEN) KIT .................. 17
LAMICTAL STARTER
(ORANGE) KIT ............... 17
LAMICTAL XR ................... 17
LAMICTAL XR STARTER
(BLUE) ............................. 17
LAMICTAL XR STARTER
(GREEN) .......................... 17
LAMICTAL XR STARTER
(ORANGE) ....................... 17
LAMISIL ................................ 3
lamivudine .............................. 4
lamivudine-zidovudine ........... 4
lamotrigine ............................ 17
LANCETS ............................ 60
LANCETS,THIN ................. 60
LANCING DEVICE WITH
LANCETS ........................ 60
LANCING SYSTEM ........... 60
LANOXIN ............................ 35
LANOXIN PEDIATRIC ...... 35
lansoprazole.......................... 74
LANTUS .............................. 65
LANTUS SOLOSTAR ........ 65
LANZO LANCING DEVICE
.......................................... 60
larin 1.5/30 (21) .................... 85
larin 1/20 (21) ....................... 85
larin 24 fe ............................. 85
larin fe 1.5/30 (28) ................ 85
larin fe 1/20 (28) ................... 85
LASIX .................................. 32
LASTACAFT ....................... 88
latanoprost ............................ 89
latrix ..................................... 40
latrix xm ............................... 40
LATUDA ............................. 27
layolis fe ............................... 85
LAZANDA........................... 22
leena 28 ................................ 85
leflunomide........................... 81
LEMTRADA........................ 75
LENVIMA ........................... 14
LESCOL ............................... 37
LESCOL XL ........................ 37
lessina ................................... 85
LETAIRIS ............................ 93
letrozole ................................ 14
leucovorin calcium ............... 11
LEUKERAN ........................ 14
LEUKINE............................. 75
leuprolide.............................. 14
levacet................................... 24
levalbuterol hcl ..................... 93
LEVAQUIN ......................... 10
LEVATOL ........................... 32
LEVBID ............................... 69
LEVEMIR ............................ 65
LEVEMIR FLEXTOUCH ... 65
levetiracetam ........................ 17
LEVETIRACETAM IN NACL
(ISO-OS) .......................... 17
levobunolol ........................... 87
levocarnitine ......................... 48
levocarnitine (with sugar)..... 48
levocetirizine ........................ 91
levofloxacin .................... 10, 87
levofloxacin in d5w .............. 10
levomefolate dha ................ 101
levomefolatepnv ................. 101
levonest (28) ......................... 85
levonorgestrel-ethinyl estrad 85
levonorg-eth estrad triphasic 85
levora-28 ............................... 85
levorphanol tartrate............... 22
levothyroxine ........................ 69
levoxyl .................................. 69
LEVSIN ................................ 69
LEVSIN/SL .......................... 69
LEVULAN ........................... 41
LEXAPRO............................ 27
LEXIVA ................................. 4
LIALDA ............................... 71
LIBERTY BLOOD
LIBERTY TEST................... 53
LIBRAX (WITH
CLIDINIUM) ................... 69
lidocaine ............................... 44
lidocaine (pf) ........................ 44
lidocaine hcl ......................... 44
lidocaine hcl-hydrocortison ac
.................................... 44, 71
LIDOCAINE HCLHYDROCORTISON AC . 71
lidocaine viscous .................. 44
lidocaine-epinephrine ........... 44
lidocaine-hydrocortisone-aloe
.......................................... 71
lidocaine-prilocaine .............. 44
LIDOCAINE-TETRACAINE
.......................................... 44
LIDODERM ......................... 44
lido-k .................................... 44
lidopin................................... 44
LIDOPIN .............................. 44
LIDORX ............................... 44
LIDOVEX ............................ 44
LIDOVIR.............................. 45
LILETTA.............................. 81
lindane .................................. 47
linezolid .................................. 8
linezolid-0.9% sodium chloride
............................................ 8
LINZESS .............................. 71
liothyronine........................... 69
LIPITOR ............................... 37
LIPOCHOL PLUS................ 48
lipodox .................................. 14
LIPOFEN .............................. 37
lisinopril ................................ 32
lisinopril-hydrochlorothiazide
.......................................... 33
LITE TOUCH LANCETS ....60
lithium carbonate .................. 27
lithium citrate........................ 27
LITHOBID ........................... 27
LITHOSTAT ........................ 48
LIVALO ............................... 37
LIVIXIL PAK ...................... 44
l-methylfolate pnv dha ........101
LO LOESTRIN FE ............... 85
LO MINASTRIN FE ............ 85
LOCAL ANESTHESIA
NEEDLE 22GX2 .............. 60
LOCOID ............................... 46
LOCOID LIPOCREAM ....... 46
LODOSYN ........................... 18
LOESTRIN 1.5/30 (21) ........85
LOESTRIN 1/20 (21) ...........85
LOESTRIN FE 1.5/30 (28DAY) ................................85
LOESTRIN FE 1/20 (28-DAY)
..........................................85
LOFIBRA .............................37
lomedia 24 fe ........................85
LOMOTIL ............................69
LONSURF ............................14
loperamide ............................69
LOPID ..................................37
lopreeza.................................82
LOPRESSOR .......................33
LOPRESSOR HCT ..............33
LOPROX ..............................45
lorazepam .............................27
lorazepam intensol ................27
lorcet (hydrocodone) ............22
lorcet hd ................................22
lorcet plus .............................22
LORTAB ..............................22
lortab 10-325 ........................22
125
lortab 5-325 .......................... 22
lortab 7.5-325 ....................... 22
LORTAB ELIXIR ................ 22
lortuss ex .............................. 91
loryna (28) ............................ 85
LORZONE ........................... 20
losartan ................................. 33
losartan-hydrochlorothiazide 33
LOSEASONIQUE ............... 85
LOTEMAX .......................... 90
LOTENSIN .......................... 33
LOTENSIN HCT ................. 33
LOTREL............................... 33
LOTRISONE........................ 45
LOTRONEX ........................ 71
LOUTREX ........................... 41
lovastatin .............................. 37
LOVENOX........................... 36
low-ogestrel (28) .................. 85
loxapine succinate ................ 27
lozi-flur ............................... 101
LP LITE PAK....................... 44
lta pre-attached ..................... 44
LUCENTIS........................... 88
ludent fluoride .................... 101
LUFYLLIN .......................... 93
lugols .................................... 97
LUMIGAN ........................... 89
LUMIZYME ........................ 66
LUNESTA............................ 27
LUPANETA PACK (1
MONTH) .......................... 83
LUPANETA PACK (3
MONTH) .......................... 83
LUPRON DEPOT ................ 14
LUPRON DEPOT (3
MONTH) .......................... 14
LUPRON DEPOT (4
MONTH) .......................... 14
LUPRON DEPOT (6
MONTH) .......................... 14
LUPRON DEPOT-PED ....... 14
LUPRON DEPOT-PED (3
MONTH) .......................... 14
lutera (28) ............................. 85
luxamend .............................. 41
LUXIQ ................................. 46
LUZU ................................... 45
LYCELLE ............................ 47
LYNPARZA ......................... 14
LYRICA ............................... 18
LYSODREN ......................... 14
LYSTEDA ............................ 83
lyza ....................................... 82
M
M.V.I. PEDIATRIC ........... 101
M.V.I.-12 (WITHOUT
VITAMIN K) ................. 101
mac ....................................... 41
macnatal cn dha .................. 101
MACROBID ........................ 11
MACRODANTIN ................ 11
MACUGEN .......................... 88
MAGNEBIND 400............... 72
MAJOR COMFORT ............ 60
MAKENA ............................ 82
MALARONE ......................... 8
MALARONE PEDIATRIC ... 8
malathion .............................. 47
maprotiline............................ 27
MAR-COF BP ...................... 91
MAR-COF CG ..................... 91
margesic................................ 22
MARINOL ........................... 72
marlissa................................. 85
MARNATAL-F .................. 101
MARPLAN .......................... 28
MARQIBO ........................... 14
marten-tab ............................. 22
MATULANE........................ 14
MAVIK ................................ 33
MAXAIR AUTOHALER .... 94
MAXALT ............................. 19
MAXALT-MLT ................... 19
MAXARON FORTE.......... 101
MAXFE (FOLATEDOCUSATE) ................. 101
MAXIDEX ........................... 90
MAXIFED (IR) .................... 91
MAXIMA ............................. 53
MAXINATE ....................... 101
MAXIPIME ............................ 6
MAXITROL ......................... 89
MAXZIDE............................ 33
MAXZIDE-25MG ................ 33
mb hydrogel .......................... 41
mb hydrogel (cyclomethicone)
.......................................... 41
126
m-clear wc ............................ 92
meclizine............................... 72
meclofenamate ...................... 24
mecobal-levomefolat ca-b6
phos................................. 101
MEDISENSE THIN
LANCETS ........................ 60
MEDLANCE PLUS
LANCETS ........................ 60
MEDROL ............................. 51
MEDROL (PAK).................. 51
medroxyprogesterone ........... 82
mefenamic acid ..................... 24
mefloquine .............................. 8
MEFOXIN IN DEXTROSE
(ISO-OSM) ......................... 6
MEGACE ............................. 14
MEGACE ES........................ 14
megestrol .............................. 14
MEKINIST ........................... 14
meloxicam ............................ 24
melphalan hcl........................ 14
memantine ............................ 20
MEMANTINE ...................... 20
MENACTRA (PF)................ 79
M-END MAX D ................... 92
M-END PE ........................... 92
MENEST .............................. 82
MENHIBRIX (PF) ............... 79
MENOMUNE - A/C/Y/W-135
..........................................79
MENOMUNE - A/C/Y/W-135
(PF) ...................................79
MENOPUR...........................66
MENOSTAR ........................82
MENTAX .............................45
MENVEO A-C-Y-W-135-DIP
(PF) ...................................79
meperidine ............................22
meperidine (pf) .....................23
MEPHYTON ........................36
meprobamate ........................20
MEPRON ...............................8
mercaptopurine .....................14
meropenem .............................8
MERREM ...............................8
mesalamine ...........................72
mesalamine with cleansing
wipe ..................................72
mesna.................................... 12
MESNEX ............................. 12
MESTINON ......................... 20
MESTINON TIMESPAN .... 20
METADATE CD ................. 28
metadate er ........................... 28
METANX ........................... 101
metaproterenol ...................... 94
metaxall ................................ 20
metaxalone ........................... 20
metformin ............................. 68
methadone ............................ 23
methadose ............................. 23
methamphetamine ................ 28
methazolamide ..................... 89
methenamine hippurate ........ 11
methenamine mandelate ....... 11
methen-sod phos-meth bluehyos .................................. 96
methergine ............................ 87
methimazole ......................... 51
METHITEST........................ 66
methocarbamol ..................... 20
methotrexate sodium ............ 14
methotrexate sodium (pf) ..... 14
methoxsalen rapid ................ 41
methscopolamine.................. 69
methyclothiazide .................. 33
methyl salicylate ................... 41
methyldopa ........................... 33
methyldopahydrochlorothiazide.......... 33
methyldopate ........................ 33
methylergonovine ................. 87
METHYLIN ......................... 28
methylphenidate ................... 28
methylprednisolone .............. 51
methyltestosterone ................ 66
metipranolol ......................... 88
metoclopramide hcl .............. 72
metolazone ........................... 33
METOPIRONE .................... 48
metoprolol succinate ............ 33
metoprolol ta-hydrochlorothiaz
.......................................... 33
metoprolol tartrate ................ 33
METOZOLV ODT ............... 72
metro i.v. ................................ 8
METROCREAM.................. 43
METROGEL ........................ 43
METROGEL VAGINAL ..... 83
METROLOTION ................. 43
metronidazole ............. 8, 43, 83
metronidazole in nacl (iso-os) 8
mexiletine ............................. 30
MIACALCIN ....................... 66
MICARDIS .......................... 33
MICARDIS HCT ................. 33
miconazole-3 ........................ 83
MICRO BLOOD GLUCOSE
.......................................... 53
MICRO THIN LANCETS ... 60
MICRODOT BLOOD
GLUCOSE SYSTEM . 53, 60
microgestin 1.5/30 (21) ........ 85
microgestin 1/20 (21) ........... 85
MICROGESTIN 24 FE ........ 85
microgestin fe 1.5/30 (28) .... 85
microgestin fe 1/20 (28) ....... 85
MICRO-K ............................. 97
MICROLET LANCET ......... 60
MICROZIDE ........................ 33
midodrine.............................. 48
migergot................................ 19
miglitol ................................. 68
MIGRALAM ........................ 19
MIGRANAL ........................ 19
millipred ............................... 51
MILLIPRED ......................... 51
millipred dp .......................... 51
mimvey ................................. 82
mimvey lo ............................. 82
MINASTRIN 24 FE ............. 85
MINI LANCING DEVICE .. 60
MINI ULTRA-THIN II ........ 60
MINIPRESS ......................... 33
MINITRAN .......................... 38
MINIVELLE ........................ 82
MINOCIN ............................ 11
MINOCIN KIT WITH WIPES
.......................................... 11
minocycline .......................... 11
minoxidil .............................. 33
MIOCHOL-E........................ 88
miostat .................................. 89
MIRAPEX ............................ 18
MIRAPEX ER ...................... 18
MIRCERA ............................ 75
MIRCETTE (28) .................. 85
MIRENA .............................. 81
mirtazapine ........................... 28
MIRVASO ............................ 43
misoprostol ........................... 74
MITIGARE........................... 80
mitomycin ............................. 14
MITOSOL ............................ 89
mitoxantrone ......................... 14
M-M-R II (PF) ...................... 79
MOBIC ................................. 24
modafinil............................... 28
moderiba ............................... 75
moderiba dose pack .............. 76
MODICON (28) ................... 85
moexipril............................... 33
moexipril-hydrochlorothiazide
.......................................... 33
molindone ............................. 28
mometasone .................... 46, 94
mondoxyne nl ....................... 11
MONOCLATE-P ................. 36
MONODOX ......................... 11
monoject 0.9% sodium
chloride ............................. 48
MONOJECT BLOOD
COLLECTION ................. 60
MONOJECT HYPODERMIC
NEEDLES ........................ 60
MONOJECT MEDICATION
TRANSF NDL.................. 60
monoject prefill (pf) ............. 36
monoject prefill advanced (pf)
.......................................... 36
monoject prefill advanced ns 48
monoject prefill saline flush . 48
MONOLET LANCETS........ 60
MONOLET THIN LANCETS
.......................................... 60
mono-linyah .......................... 85
mononessa (28) ..................... 85
MONONINE ........................ 36
montelukast........................... 94
MONUROL .......................... 11
morgidox............................... 11
MORGIDOX 2X100 ............ 11
morphine ............................... 23
MORPHINE ......................... 23
morphine (pf) ........................ 23
127
morphine concentrate ........... 23
MOTOFEN........................... 69
MOVANTIK ........................ 72
MOVIPREP .......................... 72
MOXATAG ........................... 9
MOXEZA ............................. 87
moxifloxacin......................... 10
MOXIFLOXACINSOD.ACE,SUL-WATER . 10
MOZOBIL............................ 75
MS CONTIN ........................ 23
MUCOTROL ....................... 50
MUGARD ............................ 50
MULTAQ ............................. 30
MULTICHEW ................... 101
multi-delyn with iron.......... 101
MULTI-DRAW NEEDLE ... 60
multigen folic ..................... 101
multigen plus ...................... 101
MULTI-LANCET DEVICE 2
.......................................... 60
multi-vit with fluoride-iron 101
multi-vitamin with fluoride 101
multivitamins with fluoride 101
mupirocin ............................. 44
mupirocin calcium ................ 44
MUSTARGEN ..................... 14
mvc-fluoride ....................... 101
M-VIT ................................ 101
my way ................................. 85
MYALEPT ........................... 66
MYAMBUTOL...................... 8
MYCAMINE.......................... 3
MYCOBUTIN ........................ 8
mycophenolate mofetil ......... 14
mycophenolate sodium ......... 14
mydral................................... 88
MYDRIACYL...................... 88
myferon 150 forte ............... 101
MYFORTIC ......................... 14
MYGLUCOHEALTH.... 53, 60
MYGLUCOHEALTH
LANCETS ........................ 60
MYKIDZ IRON FLUORIDE
........................................ 102
MYLERAN .......................... 14
mynatal ............................... 102
mynatal advance ................. 102
mynatal plus ....................... 102
mynatal-z ............................ 102
mynate 90 plus.................... 102
mynephrocaps ..................... 102
MYOBLOC .......................... 79
myorisan ............................... 43
MYOZYME ......................... 66
MYRBETRIQ ...................... 95
MYSOLINE ......................... 18
myzilra .................................. 85
N
NABI-HB ............................. 79
nabumetone .......................... 24
nadolol .................................. 33
nadolol-bendroflumethiazide 33
nafcillin................................... 9
nafcillin in dextrose iso-osm .. 9
nafrinse ................................. 50
naftifine ................................ 45
NAFTIFINE ......................... 45
NAFTIN ............................... 45
NAGLAZYME ..................... 66
nalbuphine ............................ 24
naloxone ............................... 24
naltrexone ............................. 24
NAMENDA.......................... 20
NAMENDA TITRATION
PAK .................................. 20
NAMENDA XR ................... 20
NAMZARIC ......................... 20
naphazoline........................... 90
NAPRELAN CR .................. 24
NAPROSYN ........................ 25
naproxen ............................... 25
naproxen sodium .................. 25
naratriptan ............................. 19
NARCAN ............................. 25
NARDIL ............................... 28
NASACORT ........................ 94
nasal allergy.......................... 94
NASONEX ........................... 94
NATA KOMPLETE........... 102
NATACHEW (FE BISGLYCINATE) ................ 102
NATACYN .......................... 87
natalvirt 90 dha ................... 102
natalvirt ca .......................... 102
NATALVIT ........................ 102
NATAZIA ............................ 85
nateglinide ............................ 68
128
NATELLE ONE ................. 102
NATESTO ............................ 66
NATPARA ........................... 66
NATRECOR......................... 38
NATROBA ...........................47
natural b-100 complex ........ 102
nature-throid ......................... 69
NAVELBINE ....................... 14
NEBUPENT ........................... 8
NEBUSAL ............................ 94
necon 0.5/35 (28) .................. 85
necon 1/35 (28) ..................... 85
necon 1/50 (28) ..................... 85
necon 10/11 (28) ................... 85
necon 7/7/7 (28) .................... 85
NEEDLES, HUBER
DISPOSABLE .................. 60
NEEVO............................... 102
NEEVODHA (WITH ALGAL
OIL) ................................ 102
nefazodone ............................ 28
neomycin ................................ 8
neomycin-bacitracin-poly-hc 89
neomycin-bacitracinpolymyxin ......................... 87
neomycin-polymyxin b gu ....47
neomycin-polymyxin bdexameth...........................89
neomycin-polymyxingramicidin .........................87
neomycin-polymyxin-hc.50, 89
neo-polycin ...........................87
neo-polycin hc ......................89
NEORAL ..............................14
NEOSALUS .........................41
NEOSPORIN (NEO-POLYMGRAMICID).....................87
NEOSPORIN GU IRRIGANT
..........................................47
NEO-SYNALAR ..................44
NEO-SYNALAR KIT .......... 44
NEOTUSS-D
(CHLORPHENIRAMINE)
..........................................92
nephplex rx .........................102
NEPHROCAPS ..................102
NEPHROCAPS QT ............102
NEPHRON FA ...................102
NEPHRO-VITE ..................102
nephro-vite rx ..................... 102
NEPTAZANE ...................... 89
NESINA ............................... 68
NESTABS .......................... 102
NESTABS ABC ................. 102
NESTABS DHA ................ 102
neuac..................................... 43
NEULASTA ......................... 75
NEUMEGA .......................... 76
NEUPOGEN ........................ 75
NEUPRO .............................. 18
NEURIN-SL ....................... 102
NEURONTIN....................... 18
NEUTEK 2TEK TEST
STRIPS ............................. 53
NEUVAXIN ......................... 41
NEVANAC .......................... 89
nevirapine ............................... 4
newgen ............................... 102
NEXA PLUS ...................... 102
NEXAVAR .......................... 14
NEXAVIR .......................... 102
NEXIUM 24HR ................... 74
NEXIUM PACKET ............. 74
NEXPLANON ..................... 83
next choice one dose ............ 85
niacin .................................... 37
NIACOR............................... 37
NIASPAN EXTENDEDRELEASE ........................ 37
nicardipine ............................ 33
NICODERM CQ .................. 49
NICOMIDE ........................ 102
NICOMIDE (SELENIUMCHROMIUM) ................ 102
NICORETTE........................ 49
nicotinamide ....................... 102
nicotine ................................. 49
NICOTINE (POLACRILEX)
.......................................... 49
NICOTROL.......................... 49
NICOTROL NS.................... 49
nifedical xl ............................ 33
nifedipine.............................. 33
nikki (28) .............................. 85
NILANDRON ...................... 14
nimodipine............................ 33
NINJACOF-XG ................... 92
NINLARO ............................ 14
NIPENT ................................ 14
NIRON KOMPLETE ......... 102
nisoldipine ............................ 33
nitro-bid ................................ 38
NITRO-DUR ........................ 38
nitrofurantoin ........................ 11
nitrofurantoin macrocrystal .. 11
nitrofurantoin monohyd/mcryst .................................. 11
nitroglycerin ......................... 38
nitroglycerin in 5 % dextrose38
NITROLINGUAL ................ 38
NITROMIST ........................ 38
NITRONAL.......................... 38
NITROSTAT ........................ 38
nitro-time .............................. 38
NIVA-FOL ......................... 102
NIVA-PLUS ....................... 102
nizatidine .............................. 74
NIZORAL ............................ 45
nodolor.................................. 19
NOKOR NEEDLE ............... 60
nora-be .................................. 82
NORCO ................................ 23
NORDITROPIN FLEXPRO 75
noreth-ethinyl estradiol-iron . 85
norethindrone (contraceptive)
.......................................... 82
norethindrone acetate ........... 82
norethindrone ac-eth estradiol
.................................... 82, 85
norethindrone-e.estradiol-iron
.......................................... 85
norgestimate-ethinyl estradiol
.......................................... 86
NORINYL 1+35 (28) ........... 86
NORINYL 1+50 (28) ........... 86
NORITATE .......................... 43
norlyroc ................................ 82
normal saline flush ............... 48
NORMOSOL-R.................... 97
NORMOSOL-R PH 7.4 ....... 98
NOROXIN............................ 10
NORPACE ........................... 30
NORPACE CR ..................... 30
NORPRAMIN ...................... 28
NOR-QD .............................. 82
NORTHERA ........................ 48
nortrel 0.5/35 (28)................. 86
nortrel 1/35 (21) .................... 86
nortrel 7/7/7 (28)................... 86
nortriptyline .......................... 28
NORVASC ...........................33
NORVIR .................................4
NOVA MAX BLOOD
GLUCOSE METER .........61
NOVA MAX GLUCOSE
TEST................................. 53
NOVA SAFETY LANCETS61
NOVA SUREFLEX
LANCETS ........................ 61
NOVACORT ........................ 72
NOVACORT (WITH ALOE)
.......................................... 44
novagesic .............................. 25
novarel .................................. 66
NOVOFINE 32 ..................... 61
NOVOFINE AUTOCOVER 61
NOVOFINE PLUS ............... 61
NOVOLIN 70/30 .................. 65
NOVOLIN N ........................ 65
NOVOLIN R ........................ 65
NOVOLOG .......................... 65
NOVOLOG FLEXPEN ........ 65
NOVOLOG MIX 70-30 ....... 65
NOVOLOG MIX 70-30
FLEXPEN......................... 65
NOVOLOG PENFILL ......... 65
NOVOPEN ECHO ............... 61
NOVOSEVEN RT................ 36
NOVOTWIST ...................... 61
NOXAFIL............................... 3
np thyroid.............................. 69
NPLATE ............................... 36
NUCORT .............................. 46
NUCYNTA........................... 25
NUCYNTA ER .................... 25
NUEDEXTA ........................ 20
NUFERA ............................ 102
NULEV................................. 69
NULOJIX ............................. 15
NULYTELY WITH FLAVOR
PACKS ............................. 72
NUOX................................... 43
NUPLAZID .......................... 28
NUTRICAP ........................ 102
NUTROPIN AQ ................... 75
NUTROPIN AQ NUSPIN .... 75
129
NUVARING......................... 83
NUVESSA ........................... 83
NUVIGIL ............................. 28
nyamyc ................................. 45
NYATA ................................ 45
NYMALIZE ......................... 33
nystatin ............................. 3, 45
nystatin-triamcinolone .......... 45
nystop ................................... 45
O
OB COMPLETE ................ 102
OB COMPLETE GOLD .... 102
OB COMPLETE ONE ....... 102
OB COMPLETE PETITE .. 102
OB COMPLETE PREMIER
........................................ 102
OB COMPLETE WITH DHA
........................................ 102
OBREDON........................... 92
obstetrix dha ....................... 102
OBSTETRIX EC ................ 102
OBTREX ............................ 102
OBTREX DHA .................. 102
O-CAL FA.......................... 102
O-CAL PRENATAL .......... 102
OCALIVA ............................ 72
ocella .................................... 86
octreotide acetate .................. 15
ocudox .................................. 11
OCUFEN .............................. 89
OCUFLOX ........................... 87
ODEFSEY .............................. 4
ODOMZO ............................ 15
OFEV ................................... 94
ofloxacin ................... 10, 50, 87
ogestrel (28).......................... 86
olanzapine............................. 28
olanzapine-fluoxetine ........... 28
OLEPTRO ER ...................... 28
olopatadine ..................... 50, 88
OLUX ................................... 46
OLUX-E ............................... 46
OLYSIO ................................. 4
OMECLAMOX-PAK .......... 74
omega-3 acid ethyl esters ..... 37
omeprazole ........................... 74
omeprazole magnesium ........ 74
OMEPRAZOLE+SYRSPEND
SF ALKA ......................... 74
omeprazole-sodium
bicarbonate ....................... 74
OMIDRIA ............................ 88
OMNARIS............................ 94
OMNIPRED ......................... 90
OMNITROPE....................... 75
ON CALL EXPRESS METER
.......................................... 61
ON CALL EXPRESS TEST
STRIP ............................... 53
ON CALL LANCET ............ 61
ON CALL LANCING
DEVICE ........................... 61
ON CALL PLUS LANCET . 61
ON CALL PLUS LANCING
DEVICE ........................... 61
ON CALL PLUS METER ... 61
ON CALL PLUS TEST STRIP
.......................................... 53
ON CALL VIVID METER .. 61
ON CALL VIVID PAL
METER ............................ 61
ON CALL VIVID TEST
STRIP ............................... 54
ONCASPAR......................... 15
ondansetron .......................... 72
ondansetron hcl..................... 72
ondansetron hcl (pf).............. 72
ONE A DAY WOMEN'S
PRENATAL DHA ......... 102
one daily prenatal ............... 103
ONE DAILY PRENATAL 103
ONETOUCH DELICA LANC
DEVICE ........................... 61
ONETOUCH FINEPOINT
LANCETS ........................ 61
ONETOUCH SURESOFT
LANCING DEV ............... 61
ONETOUCH ULTRA TEST
.......................................... 54
ONETOUCH ULTRA2 ........ 61
ONETOUCH ULTRAMINI. 61
ONETOUCH ULTRASOFT
LANCETS ........................ 61
ONETOUCH VERIO ........... 54
ONETOUCH VERIO FLEX 61
ONETOUCH VERIO IQ
METER ............................ 61
130
ONETOUCH VERIO SYNC
.......................................... 61
ONETOUCH VERIO
SYSTEM .......................... 61
ONEXTON ........................... 43
ONFI ..................................... 18
ONGLYZA ........................... 68
ONMEL .................................. 3
ONSOLIS ............................. 23
ON-THE-GO LANCETS ..... 61
OPANA ................................ 23
OPANA ER .......................... 23
opcicon one-step ................... 86
OPDIVO ...............................15
opium tincture .......................70
OPSUMIT............................. 94
OPTIUM EZ ......................... 54
OPTIUM TEST .................... 54
OPTUMRX..................... 54, 61
ORACEA .............................. 11
ORACIT ............................... 96
ORAFATE ............................ 50
ORALAIR ............................ 79
oralone .................................. 50
ORAMAGICRX ................... 50
ORAP ................................... 28
ORAPRED ........................... 51
ORAPRED ODT .................. 51
ORAVIG................................. 3
ORBACTIV ............................ 8
ORENCIA ............................ 81
ORENCIA (WITH
MALTOSE) ...................... 81
ORENCIA CLICKJECT ...... 81
ORENITRAM ...................... 33
ORFADIN ............................ 48
ORKAMBI ........................... 94
orphenadrine citrate .............. 20
orsythia ................................. 86
ortho d ................................. 103
ORTHO MICRONOR .......... 82
ORTHO TRI-CYCLEN (28) 86
ORTHO TRI-CYCLEN LO
(28) ................................... 86
ORTHO-CYCLEN (28) ....... 86
ORTHO-NOVUM 1/35 (28) 86
ORTHO-NOVUM 7/7/7 (28)
.......................................... 86
oscimin ................................. 70
oscimin sl.............................. 70
oscimin sr ............................. 70
OSENI .................................. 68
OSMOPREP ......................... 72
OSPHENA ........................... 83
OTEZLA .............................. 81
OTEZLA STARTER............ 81
OTIC CARE (ANTIPYRINE)
.......................................... 50
oticin ..................................... 50
otomax-hc ............................. 50
otozin .................................... 50
OTREXUP (PF) ................... 81
OVACE ................................ 39
OVACE PLUS ..................... 39
OVACE PLUS SHAMPOO . 39
OVACE PLUS WASH......... 39
OVCON-35 (28)................... 86
OVIDE ................................. 47
OVIDREL ............................ 66
oxacillin .................................. 9
oxacillin in dextrose(iso-osm) 9
oxaliplatin ............................. 15
OXANDRIN......................... 67
oxandrolone .......................... 67
oxaprozin .............................. 25
OXAYDO............................. 23
oxazepam.............................. 28
oxcarbazepine ....................... 18
oxiconazole........................... 45
OXISTAT ............................. 45
OXSORALEN...................... 41
OXSORALEN ULTRA ....... 41
OXTELLAR XR .................. 18
oxybutynin chloride.............. 95
oxycodone ............................ 23
OXYCODONE..................... 23
oxycodone-acetaminophen ... 23
oxycodone-aspirin ................ 23
OXYCONTIN ...................... 23
oxymorphone........................ 23
OXYTROL ........................... 95
P
pacerone ............................... 30
paclitaxel .............................. 15
PACNEX .............................. 43
pain relief (capsaicin) ........... 41
PAIRE OB PLUS DHA ..... 103
paliperidone .......................... 28
PAMELOR ........................... 28
pamidronate .......................... 67
PAMINE FQ......................... 70
PANCREAZE ...................... 72
PANDEL .............................. 46
PANRETIN .......................... 41
pantoprazole ......................... 74
papaverine ............................ 33
PARAFON FORTE DSC ..... 21
PARAGARD T 380A........... 81
PARASYMPATH NERVE
NDL 20 G X6 ................... 61
parcaine ................................ 88
paregoric ............................... 70
PAREMYD .......................... 88
paricalcitol ............................ 67
PARICALCITOL ................. 67
PARLODEL ......................... 18
PARNATE............................ 28
paromomycin .......................... 8
paroxetine hcl ....................... 28
PASER.................................... 8
PATADAY ........................... 88
PATANASE ......................... 50
PATANOL ........................... 88
PAXIL .................................. 28
PAXIL CR ............................ 28
PAZEO ................................. 88
PCE......................................... 6
PED MULTIVITAMINSA,B,D,E,K,ZN ................ 103
PEDIADERM AF................. 45
PEDIADERM HC ................ 46
PEDIADERM TA ................ 46
PEDIAPRED ........................ 51
PEDIARIX (PF) ................... 79
PEDVAX HIB (PF) .............. 79
peg 3350-electrolytes ........... 72
peg-3350 with flavor packs .. 72
PEGANONE ........................ 18
PEGASYS ............................ 76
PEGASYS PROCLICK ....... 76
peg-electrolyte soln .............. 72
PEGINTRON ....................... 76
PEGINTRON REDIPEN ..... 76
peg-prep ................................ 72
pe-guai .................................. 92
PEN NEEDLE ...................... 61
PEN NEEDLE, DIABETIC . 61
PENICILLIN G POT IN
DEXTROSE ....................... 9
penicillin g potassium ............. 9
penicillin g procaine ............... 9
penicillin g sodium ................. 9
penicillin v potassium ........... 10
PENLAC............................... 45
PENNSAID .......................... 25
PENTACEL (PF).................. 79
PENTAM ................................ 8
PENTASA ............................ 72
pentazocine-naloxone ........... 25
PENTIPS .............................. 61
PENTIPS PEN NEEDLE .....61
pentoxifylline ........................36
PEPCID ................................74
PERCOCET..........................23
PERFOROMIST...................94
perindopril erbumine ............33
PERJETA ............................. 15
permethrin............................. 47
perphenazine ......................... 28
perphenazine-amitriptyline ...28
perry prenatal ...................... 103
PERSANTINE ...................... 36
PERTZYE............................. 72
PEXEVA .............................. 28
pfizerpen-g ............................ 10
PHARMACIST CHOICE .... 54
PHARMACIST CHOICE
GLUCOSE SYS ............... 61
PHASEAL PROTECTOR .... 61
phenadoz ............................... 91
phenazopyridine ................... 96
phenazopyridine plus ............ 96
phenelzine ............................. 28
phenergan ............................. 91
PHENERGAN ...................... 91
phenobarbital ........................ 18
phenohytro ............................ 70
phenoxybenzamine ............... 33
phentolamine ........................ 33
PHENTOLAMINE ............... 33
phenylephrine hcl ................. 90
phenylhistine dh.................... 92
PHENYTEK ......................... 18
phenytoin .............................. 18
phenytoin sodium ................. 18
phenytoin sodium extended .. 18
131
philith ................................... 86
PHOSLO .............................. 72
PHOSLYRA ......................... 72
phospha 250 neutral ............. 97
phosphasal ............................ 96
PHOSPHOLINE IODIDE .... 88
PHOTOFRIN ....................... 15
PHRENILIN FORTE ........... 23
PHYSICIANS EZ USE FLU
2012-13............................. 79
PHYSIOLYTE ..................... 47
PHYSIOSOL IRRIGATION 47
PHYTONADIONE
(VITAMIN K1) ................ 36
PICATO ............................... 41
pilocarpine hcl .......... 48, 50, 88
PILOPINE HS ...................... 88
pimozide ............................... 28
pimtrea (28) .......................... 86
pindolol................................. 33
pioglitazone .......................... 68
pioglitazone-glimepiride ...... 68
pioglitazone-metformin ........ 68
piperacillin-tazobactam ........ 10
pirmella................................. 86
piroxicam.............................. 25
PLAN B ONE-STEP ............ 86
PLAQUENIL ......................... 8
PLASMA-LYTE 148 ........... 98
PLASMA-LYTE A .............. 98
PLAVIX ............................... 36
PLEGRIDY .......................... 76
PLEXION ............................. 43
PLEXION CLEANSING
CLOTHS .......................... 43
PLIAGLIS ............................ 44
PNEUMOVAX 23 ............... 79
pnv 29-1.............................. 103
PNV FOLIC ACID + IRON
........................................ 103
pnv ob+dha ......................... 103
pnv-dha ............................... 103
pnv-dha + docusate ............ 103
pnv-ferrous fumarate-docu-fa
........................................ 103
pnv-omega .......................... 103
pnv-select ........................... 103
pnv-total ............................. 103
pnv-vp-u ............................. 103
PODOCON........................... 40
podofilox .............................. 41
POLY HIST NC ................... 92
POLY HUB NEEDLE.......... 61
polycin .................................. 87
polycin b ............................... 87
poly-dex ................................ 89
poly-iron 150 forte.............. 103
polymyxin b sulfate ................ 8
polymyxin b sulf-trimethoprim
.......................................... 87
POLYTRIM.......................... 87
POLY-TUSSIN AC .............. 92
poly-tussin d ......................... 92
POLY-VI-FLOR ................ 103
POLY-VI-FLOR FS ........... 103
POLY-VI-FLOR WITH IRON
........................................ 103
poly-vitamin with iron ........ 103
POMALYST ........................ 76
PONSTEL ............................ 25
portia..................................... 86
pot,sodium citrate-citric acid 96
POTABA .............................. 97
potassium acetate .................. 97
potassium bicarb and chloride
.......................................... 97
potassium bicarb-citric acid.. 97
potassium chlorid-d50.45%nacl ......................... 97
potassium chloride................ 97
potassium chloride in 0.9%nacl
.......................................... 97
potassium chloride in 5 % dex
.......................................... 97
potassium chloride in lr-d5 ... 97
potassium chloride-0.45 % nacl
.......................................... 97
potassium chloride-d50.2%nacl ........................... 97
potassium citrate ................... 96
potassium citrate-citric acid.. 96
POTASSIUM HYDROXIDE
.......................................... 40
132
potassium phosphate m-/dbasic .................................. 97
POTIGA ............................... 18
PR BENZOYL PEROXIDE .43
pr natal 400 ......................... 103
pr natal 400 ec .................... 103
pr natal 430 ......................... 103
pr natal 430 ec .................... 103
PRADAXA ........................... 36
PRALUENT PEN ................. 37
PRALUENT SYRINGE ....... 37
pramcort ................................ 72
pramipexole .......................... 18
PRAMOSONE ..................... 39
PRAMOSONE E .................. 39
PRANDIN ............................ 68
PRAVACHOL...................... 37
pravastatin............................. 37
prazosin................................. 33
PRECISION PCX PLUS TEST
.......................................... 54
PRECISION PCX TEST ...... 54
PRECISION POINT OF
CARE TEST ..................... 54
PRECISION Q-I-D TEST .... 54
PRECISION XTRA
MONITOR ....................... 61
PRECISION XTRA TEST ... 54
PRECOSE............................. 68
PRED FORTE ...................... 90
PRED MILD ......................... 90
PRED-G ................................ 89
PRED-G S.O.P. .................... 89
prednicarbate ........................ 46
prednisolone ......................... 51
prednisolone acetate ............. 90
prednisolone sodium phosphate
.................................... 51, 90
prednisone............................. 51
prednisone intensol ............... 51
PREFERA-OB .................... 103
PREFERA-OB ONE .......... 103
PREFERA-OB PLUS DHA
........................................ 103
PREFEST ............................. 82
PREGNYL............................ 67
PREMARIN ......................... 82
PREMIUM BLOOD
PREMIUM V10 ............. 54, 62
PREMPHASE ...................... 82
PREMPRO ........................... 83
prena1 chew........................ 103
prena1 pearl ........................ 103
prenaissance ....................... 103
prenaissance 90 dha ............ 103
prenaissance harmony dha . 103
prenaissance next................ 103
PRENAISSANCE NEXT-B
........................................ 103
prenaissance plus ................ 103
prenaissance promise.......... 103
PRENATA ......................... 103
prenatabs fa ........................ 103
prenatabs rx ........................ 103
prenatal ............................... 103
PRENATAL + DHA .......... 103
prenatal complete ............... 103
prenatal formula ................. 103
prenatal one daily ............... 103
prenatal plus ....................... 103
prenatal plus (calcium carb)103
prenatal vit#96-ferrous fum-fa
........................................ 103
prenatal vitamin .................. 103
prenatal vitamin plus low iron
........................................ 103
prenatal-u ............................ 104
PRENATE AM .................. 104
PRENATE CHEWABLE... 104
PRENATE DHA (FERR ASP
GLYCIN) ....................... 104
PRENATE ELITE (IRON ASP
GLYC)............................ 104
PRENATE ENHANCE ...... 104
PRENATE
ESSENTIAL(IRON-ASPGL) ................................. 104
PRENATE MINI ................ 104
PRENATE MINI (FERR ASP
GLYCIN) ....................... 104
PRENATE PIXIE ............... 104
PRENATE RESTORE ....... 104
PRENATE STAR............... 104
PREPIDIL ............................ 83
preplus ................................ 104
PREPOPIK ........................... 72
PREQUE 10 ....................... 104
PRESERA ............................ 41
PRESSURE ACTIVATED
LANCETS ........................ 62
PRESTALIA ........................ 33
PRESTO PRO BLOOD
pretab .................................. 104
PREVACID 24HR ............... 74
PREVACID SOLUTAB....... 74
prevalite ................................ 37
PREVIDENT ........................ 50
PREVIDENT 5000 BOOSTER
PLUS ................................ 50
PREVIDENT 5000 DRY
MOUTH ........................... 50
PREVIDENT 5000 ENAMEL
PROTECT ........................ 50
PREVIDENT 5000
SENSITIVE ...................... 50
previfem................................ 86
PREVNAR 13 (PF) .............. 79
PREVPAC ............................ 74
PREZCOBIX .......................... 4
PREZISTA ............................. 4
PRIFTIN ................................. 8
PRILOSEC ........................... 74
PRILOSEC OTC .................. 74
PRIMAQUINE ....................... 8
PRIMAXIN IV ....................... 8
primidone.............................. 18
PRIMLEV ............................ 23
PRIMSOL............................. 11
PRINIVIL ............................. 33
PRISTIQ ............................... 28
PROAIR HFA ...................... 94
PROAIR RESPICLICK ....... 94
probenecid ............................ 80
procainamide ........................ 30
PROCARDIA ....................... 33
PROCARDIA XL................. 33
procentra ............................... 28
prochlorperazine ................... 72
prochlorperazine edisylate.... 72
prochlorperazine maleate ..... 72
PRO-CLEAR CAPS ............. 92
PROCORT............................ 72
PROCRIT ............................. 75
PROCTOCORT.................... 72
PROCTOFOAM HC ............ 72
procto-med hc ....................... 72
procto-pak ............................. 72
proctosol hc .......................... 72
proctozone-hc ....................... 72
PROCYSBI...........................96
PRODIGY ............................54
PRODIGY AUTOCODE
METER............................. 62
PRODIGY AUTOCODE
MONITOR SYST ............. 62
PRODIGY LANCETS ......... 62
PRODIGY LANCING
DEVICE ........................... 62
PRODIGY NO CODING ..... 54
PRODIGY POCKET METER
.......................................... 62
PRODIGY TWIST TOP
LANCET .......................... 62
PRODIGY VOICE GLUCOSE
METER............................. 62
PRODRIN............................. 19
PROFERRIN-FORTE ........ 104
PROFILNINE ....................... 36
progesterone ......................... 83
progesterone micronized ...... 83
PROGLYCEM ..................... 55
PROGRAF ............................ 15
PROLASTIN-C .................... 48
PROLENSA ......................... 89
PROLEUKIN ....................... 76
PROLIA ................................ 80
PROMACTA ........................ 36
promethazine ........................ 91
promethazine vc.................... 92
promethazine vc-codeine ...... 92
promethazine-codeine........... 92
promethazine-dm .................. 92
promethazine-phenylephcodeine .............................. 92
promethegan ......................... 91
PROMETRIUM ................... 83
PROMISEB .......................... 41
PROMISEB COMPLETE .... 39
propafenone .......................... 30
propantheline ........................ 70
proparacaine ......................... 89
propranolol ..................... 33, 34
propranolol-hydrochlorothiazid
.......................................... 34
133
propylthiouracil .................... 51
PROQUAD (PF) .................. 79
PRO-RED AC (W/
DEXCHLORPHENIR) .... 92
PROSCAR............................ 95
PROSTIN E2 ........................ 83
PROSTIN VR PEDIATRIC . 96
protamine.............................. 36
PROTECT BONE .............. 104
PROTECT IRON ............... 104
PROTECT NATAL............ 104
PROTHELIAL ..................... 50
PROTONIX.......................... 74
PROTOPIC........................... 41
protriptyline .......................... 28
PROVENTIL HFA............... 94
PROVERA ........................... 83
PROVIDA DHA ................ 104
PROVIDA OB.................... 104
PROVIGIL ........................... 28
PROZAC .............................. 28
PROZAC WEEKLY ............ 28
pruclair ................................. 41
prudoxin ............................... 41
prumyx ................................. 41
prutect ................................... 41
PSORCON ........................... 47
PULMICORT ....................... 94
PULMICORT FLEXHALER
.......................................... 94
pulmosal ............................... 94
PULMOZYME..................... 94
PURALOR CI .................... 104
PUREFE OB PLUS ............ 104
PUREFE PLUS .................. 104
purevit dualfe plus .............. 104
PURIXAN ............................ 15
PYLERA .............................. 74
pyrazinamide .......................... 8
PYRIDIUM .......................... 96
pyridostigmine bromide ....... 21
Q
Q-CARE RX Q4................... 50
QNASL................................. 94
QROXIN .............................. 41
QUADRACEL (PF) ............. 79
QUALAQUIN ........................ 8
QUARTETTE ...................... 86
quasense ............................... 86
quazepam .............................. 28
QUDEXY XR....................... 18
QUESTRAN......................... 37
QUESTRAN LIGHT ............ 37
quetiapine ............................. 28
QUFLORA PEDIATRIC ... 104
QUFLORA PEDIATRIC
DROPS ........................... 104
QUILLICHEW ER ............... 28
QUILLIVANT XR ............... 28
quinapril................................ 34
quinapril-hydrochlorothiazide
.......................................... 34
quinidine gluconate .............. 30
quinidine sulfate ................... 30
quinine sulfate ........................ 8
QUINTET AC ...................... 54
QUINTET BLOOD
QUIT 2 ................................. 49
QUIT 4 ................................. 49
QUTENZA ........................... 41
QVAR ................................... 94
R
rabeprazole ........................... 74
RADIOGARDASE .............. 48
RAGWITEK ......................... 79
raloxifene .............................. 80
ramipril ................................. 34
RANEXA ............................. 38
ranitidine hcl ......................... 74
RAPAFLO ............................ 95
RAPAMUNE........................ 15
RAPIVAB .............................. 4
RASUVO (PF) ..................... 81
RAVICTI .............................. 48
RAYOS ................................ 51
RAZADYNE ........................ 20
RAZADYNE ER .................. 20
rea lo 39 ................................ 41
rea lo 40 ................................ 41
react ...................................... 86
REBETOL ............................ 76
REBIF (WITH ALBUMIN) . 76
REBIF REBIDOSE .............. 76
REBIF TITRATION PACK. 76
RECLAST ............................ 48
reclipsen (28) ........................ 86
RECOMBINATE ................. 36
134
RECOMBIVAX HB (PF)..... 79
RECTIV ................................ 72
REFUAH PLUS ................... 54
REFUAH PLUS GLUCOSE
MONITOR ....................... 62
REGLAN .............................. 72
regonol ..................................21
REGRANEX ........................41
relador pak ............................ 44
relador pak plus .................... 44
RELAGARD ........................ 83
RELAGESIC ........................ 25
relcof c .................................. 92
RELENZA DISKHALER ...... 4
RELIAMED LANCET ......... 62
RELIAMED MINI LANCING
DEVICE ........................... 62
RELIAMED SAFETY SEAL
LANCETS ........................ 62
RELION CONFIRM ............ 62
RELION CONFIRM-MICRO
.......................................... 54
RELION MICRO GLUCOSE
MONITOR ....................... 62
RELION NEEDLES ............. 62
RELION PEN NEEDLES .... 62
RELION PRIME METER ....62
RELION PRIME TEST
STRIPS ............................. 54
RELION THIN LANCETS .. 62
RELION ULTRA THIN PLUS
LANCETS ........................ 62
RELISTOR ........................... 72
relnate dha .......................... 104
RELPAX............................... 19
RELYYT .............................. 41
REMERON........................... 28
REMERON SOLTAB ..........28
REMESENSE ....................... 50
remeven ................................ 41
REMICADE ......................... 72
REMODULIN ...................... 34
RENACIDIN ........................ 96
RENAGEL ........................... 72
renal caps ............................ 104
RENAL VITAMIN ............ 104
rena-vite .............................. 104
rena-vite rx.......................... 104
RENAX .............................. 104
reno caps ............................. 104
RENOVO ............................. 41
RENVELA ........................... 72
repaglinide ............................ 68
repaglinide-metformin.......... 68
REPATHA SURECLICK .... 37
REPATHA SYRINGE ......... 37
reprexain ............................... 23
REQUIP ............................... 19
REQUIP XL ......................... 19
RESCRIPTOR ........................ 4
RESCULA............................ 89
reserpine ............................... 34
RESPA-AR........................... 92
RESTASIS ........................... 89
RESTORIL ........................... 28
RETIN-A .............................. 43
RETIN-A MICRO ................ 43
RETIN-A MICRO PUMP .... 43
RETISERT ........................... 90
RETROVIR ............................ 4
REVATIO ............................ 94
REVEAL BLOOD GLUCOSE
METER ............................ 62
REVEAL TEST STRIP ........ 54
REVESTA .......................... 104
REVIA.................................. 25
REVLIMID .......................... 76
revonto.................................. 21
REXULTI ............................. 28
REYATAZ ............................. 4
REZIRA ............................... 92
RHEUMATREX .................. 15
RHINOCORT AQUA .......... 94
rhinoflex ............................... 25
RIASTAP ............................. 36
ribasphere ............................. 76
ribasphere ribapak ................ 76
ribavirin ................................ 76
RIDAURA............................ 81
rifabutin .................................. 8
RIFADIN ................................ 8
RIFAMATE ........................... 8
rifampin .................................. 8
RIFATER ............................... 8
RIGHT STEP PRENATAL
VITAMINS .................... 104
RIGHTEST GD500
RIGHTEST GL300 LANCETS
.......................................... 62
RIGHTEST GM550 SYSTEM
.......................................... 62
RIGHTEST GS550 TEST
STRIPS ............................. 54
RILUTEK ............................. 48
riluzole .................................. 48
rimantadine ............................. 4
ringers ................................... 47
RIOMET ............................... 68
risacal-d .............................. 104
risedronate ...................... 48, 80
RISPERDAL ........................ 28
RISPERDAL CONSTA ....... 28
RISPERDAL M-TAB .......... 28
risperidone ............................ 28
RITALIN .............................. 29
RITALIN LA ........................ 29
RITUXAN ............................ 15
rivastigmine .......................... 20
rivastigmine tartrate .............. 20
RIXUBIS .............................. 36
rizatriptan.............................. 19
R-NATAL OB .................... 104
ROBAXIN ............................ 21
ROBAXIN-750 .................... 21
ROBINUL ............................ 70
ROBINUL FORTE............... 70
ROCALTROL ...................... 67
romycin ................................. 87
ropinirole .............................. 19
rosadan.................................. 43
ROSANIL............................. 43
ROSULA .............................. 43
rosula cleansing cloths.......... 43
rosuvastatin........................... 37
ROTARIX ............................ 79
ROTATEQ VACCINE......... 79
ROWASA............................. 72
roweepra ............................... 18
ROXICODONE.................... 23
ROZEREM ........................... 29
r-tanna ................................... 92
RUCONEST ......................... 94
ru-hist forte ........................... 92
rulavite dha ......................... 104
RYANODEX........................ 21
RYBIX ODT ........................ 25
rydex ..................................... 92
RYNODERM ....................... 41
RYTARY .............................. 19
RYTHMOL .......................... 30
RYTHMOL SR .................... 30
S
SABRIL ................................ 18
SAFETY LANCETS ............62
SAFETY SEAL LANCETS .62
SAFETY-LET LANCETS ...62
SAFYRAL ............................ 86
SAIZEN ................................75
SAIZEN CLICK.EASY ....... 75
salacyn ..................................40
SALAGEN .....................48, 50
SALEX .................................40
salicylic acid .........................40
salicylic acid er-ceramides ...40
SALKERA ............................40
salsalate.................................25
salvax ....................................40
SALVAX DUO PLUS .........40
SAMSCA..............................67
SANCUSO ...........................72
SANDIMMUNE...................15
SANDOSTATIN ..................15
SANDOSTATIN LAR
DEPOT .............................15
SANTYL ..............................47
SAPHRIS (BLACK
CHERRY).........................29
SARAFEM ...........................29
SAVAYSA ...........................36
SAVELLA ............................81
scalacort ................................47
SCALACORT DK................47
SEASONIQUE .....................86
seb-prev ................................39
seconal sodium .....................29
SECTRAL ............................34
SEEBRI NEOHALER ..........94
SELECT-OB.......................104
SELECT-OB + DHA ..........104
selegiline hcl .........................19
selenium sulfide ....................39
SELRX .................................39
SELZENTRY .........................4
SEMPREX-D .......................92
se-natal 19 ...........................104
135
se-natal 19 (with docusate). 104
SENSIPAR ........................... 67
SEREVENT DISKUS .......... 94
SEROQUEL ......................... 29
SEROQUEL XR .................. 29
SEROSTIM .......................... 75
sertraline ............................... 29
se-tan dha............................ 104
se-tan plus ........................... 104
setlakin ................................. 86
sf 50
sf 5000 plus .......................... 50
sharobel ................................ 83
SHOHL'S MODIFIED ......... 96
SIDEROL ........................... 104
SIGNIFOR ........................... 15
SIGNIFOR LAR .................. 15
sildenafil ............................... 94
SILENOR ............................. 29
SILMANIX .......................... 41
SILVADENE ....................... 39
silver nitrate .......................... 41
silver nitrate applicators ....... 41
silver sulfadiazine................. 39
SIMBRINZA ........................ 89
SIMPONI ............................. 81
SIMPONI ARIA ................... 81
SIMULECT .......................... 15
simvastatin............................ 37
sinelee ................................... 41
SINELEE.............................. 41
SINEMET............................. 19
SINEMET CR ...................... 19
SINGLE USE EZ FLU 201213 (PF) .............................. 79
SINGLE USE EZ FLU 201314 (PF) .............................. 79
SINGLE USE EZ FLU 201415(PF) ............................... 79
SINGLE-LET ....................... 62
SINGULAIR ........................ 94
SINOGRAFIN ...................... 48
sirolimus ............................... 15
SIRTURO ............................... 8
SITAVIG ................................ 4
SIVEXTRO ........................ 8, 9
SKELAXIN .......................... 21
SKLICE ................................ 47
SKYLA................................. 81
SMART SENSE LANCETS 62
SMART SENSE
MONITORING SYSTEM 62
SMART SENSE TEST
STRIPS ............................. 54
SMARTDIABETES
VANTAGE ....................... 62
SMARTEST EJECT............. 62
SMARTEST LANCET ........ 62
SMARTEST PERSONA
STARTER ........................ 63
SMARTEST PRONTO
STARTER ........................ 63
SMARTEST PROTEGE ...... 63
SMARTEST TEST............... 54
SNAP INSULIN PUMP
CONTROLLER................ 63
SNAP INSULIN PUMPINFUSION SET ............... 63
sodium chlor 0.9% bacteriostat
.......................................... 48
sodium chloride .............. 94, 97
sodium chloride 0.45 % ........ 97
sodium chloride 0.9 % .......... 49
SODIUM CHLORIDE 0.9 %
.......................................... 49
sodium chloride 3 % ............. 98
sodium chloride 5 % ............. 98
sodium citrate-citric acid ...... 96
SODIUM EDECRIN ............ 34
sodium ferric gluconat-sucrose
.......................................... 49
sodium fluoride..... 50, 104, 105
sodium phenylbutyrate ......... 49
sodium phosphate ................. 98
sodium polystyrene sulfonate
.......................................... 72
SODIUM POLYSTYRENE
SULFONATE ................... 73
SOFT TOUCH LANCETS .. 63
SOFTGELS MULTIVITA,B,D,E,K,ZN ................ 105
SOLAICE ............................. 41
SOLARAZE ......................... 41
SOLIRIS ............................... 49
SOLODYN ........................... 11
SOLTAMOX ........................ 15
SOLUS V2 AUDIBLE
METER ............................ 63
136
SOLUS V2 LANCETS......... 63
SOLUS V2 LANCING
DEVICE ........................... 63
SOLUS V2 TEST STRIPS ... 54
SOMA...................................21
SOMATULINE DEPOT ......15
SOMAVERT ........................67
sonafine.................................41
SONATA ..............................29
SOOLANTRA ......................43
SORBITOL........................... 47
SORBITOL-MANNITOL .... 47
SORIATANE ....................... 39
SORILUX ............................. 39
sotalol ................................... 30
SOTALOL ............................ 30
sotalol af ............................... 30
SOTYLIZE ........................... 30
SOVALDI............................... 4
SPECTRACEF ....................... 6
spinosad ................................ 47
SPIRIVA RESPIMAT .......... 94
SPIRIVA WITH
HANDIHALER ................ 94
spironolactone....................... 34
spironolacton-hydrochlorothiaz
.......................................... 34
SPORANOX........................... 3
SPORANOX PULSEPAK ..... 3
sprintec (28) .......................... 86
SPRITAM ............................. 18
SPRIX ................................... 25
SPRYCEL............................. 15
sps ......................................... 73
sronyx ................................... 86
ss 10-2 ................................... 43
ssd ......................................... 39
SSKI ..................................... 51
SSS 10-4 ............................... 43
sss 10-5 ................................. 43
STALEVO 100 ..................... 19
STALEVO 125 ..................... 19
STALEVO 150 ..................... 19
STALEVO 200 ..................... 19
STALEVO 50 ....................... 19
STALEVO 75 ....................... 19
STARLIX ............................. 68
stavudine ................................. 4
STELARA ............................ 39
STERILANCE TL................ 63
STIMATE............................. 67
STIOLTO RESPIMAT ........ 94
STIVARGA.......................... 15
STRATTERA ....................... 29
STRENSIQ ........................... 67
STREPTOMYCIN ................. 9
stress formula ..................... 105
stress formula with iron ...... 105
stress formula with iron(sulf)
........................................ 105
STRIANT ............................. 67
STRIBILD .............................. 4
STRIVERDI RESPIMAT .... 94
STROMECTOL ..................... 9
strong iodine ......................... 98
strovite ................................ 105
STROVITE FORTE ........... 105
STROVITE ONE ............... 105
strovite plus ........................ 105
SUBOXONE ........................ 25
SUBSYS ............................... 23
SUCLEAR ............................ 73
SUCRAID ............................ 73
sucralfate .............................. 74
SULAR ................................. 34
sulfacetamide sodium ..... 39, 90
sulfacetamide sodium (acne) 44
sulfacetamide sodium-sulfur 43
sulfacetamide sodium-urea ... 39
sulfacetamide sod-sulfur-urea
.......................................... 43
sulfacetamide-prednisolone.. 90
sulfacetamide-sulfur-cleansr23
.......................................... 43
sulfacleanse 8-4 .................... 43
sulfact na-sul-avobnz-otn-ocsa
.......................................... 43
sulfadiazine........................... 10
sulfamethoxazole-trimethoprim
.......................................... 10
SULFAMYLON................... 44
sulfasalazine ......................... 73
sulfatrim ............................... 10
SULFUR............................... 40
sulindac................................. 25
SUMADAN.......................... 43
SUMADAN XLT ................. 43
sumatriptan ........................... 19
sumatriptan succinate ........... 19
SUMAVEL DOSEPRO ....... 19
SUMAXIN ........................... 43
SUMAXIN CP ..................... 43
SUMAXIN TS ...................... 43
SUPER THIN LANCETS .... 63
SUPERVITE ...................... 105
SUPERVITE (EC) .............. 105
SUPRAX ................................ 6
SUPREP BOWEL PREP KIT
.......................................... 73
SURE COMFORT LANCETS
.......................................... 63
SURE COMFORT LANCING
PEN .................................. 63
SURE COMFORT PEN
NEEDLE .......................... 63
SURE EDGE BLOOD
SURE-FINE PEN NEEDLES
.......................................... 63
SUREFLEX LANCING
DEVICE ........................... 63
SURE-LANCE ..................... 63
SURE-PEN LANCING
DEVICE ........................... 63
SURE-TEST EASYPLUS
MINI ................................. 54
SURE-TEST EASYPLUS
MINI METER .................. 63
SURE-TOUCH LANCET .... 63
SURFAXIN .......................... 94
SURGUARD2 SAFETY ...... 63
SURMONTIL....................... 29
SURVANTA ........................ 49
SUSTIVA ............................... 4
SUTENT............................... 15
SWABFLUSH ...................... 49
syeda ..................................... 86
SYLATRON ......................... 76
SYLVANT ........................... 15
SYMAX DUOTAB .............. 70
symax fastabs ....................... 70
symax-sl................................ 70
symax-sr ............................... 70
SYMBICORT....................... 94
SYMBYAX .......................... 29
SYMLINPEN 120 ................ 68
SYMLINPEN 60 .................. 68
SYNAGEX ......................... 105
SYNALAR ........................... 47
SYNALAR CREAM KIT .... 47
SYNALAR OINTMENT KIT
.......................................... 47
SYNALAR TS...................... 47
SYNALGOS-DC .................. 23
SYNAPRYN.........................25
SYNAREL............................67
SYNERA ..............................44
SYNJARDY .........................68
SYNRIBO............................. 15
SYNTHROID ....................... 69
SYPRINE ............................. 49
syrex sodium chloride 0.9% .49
T
T
SLIM.................................63
SLIM G4 ...........................63
TABLOID.............................15
TACLONEX.........................39
tacrolimus .......................15, 41
TAFINLAR ..........................15
TAGRISSO...........................15
TAKE ACTION ...................86
TALTZ AUTOINJECTOR ..39
TALTZ AUTOINJECTOR (2
PACK) ..............................39
TALTZ AUTOINJECTOR (3
PACK) ..............................39
TALTZ SYRINGE ...............39
TALTZ SYRINGE (2 PACK)
..........................................39
TALTZ SYRINGE (3 PACK)
..........................................39
TALWIN ..............................25
TAMIFLU ..............................4
tamoxifen ..............................15
tamsulosin .............................95
TANDEM F ........................105
TANDEM PLUS ................105
TANZEUM...........................68
TAPAZOLE .........................51
TARCEVA ...........................15
TARGRETIN .......................15
tarina fe 1/20 (28) .................86
TARKA ................................34
taron forte ...........................105
taron-c dha ..........................105
137
taron-prex prenatal-dha ...... 105
TASIGNA ............................ 15
TASMAR ............................. 19
TAXOTERE ......................... 15
TAZICEF ............................... 6
TAZORAC ........................... 43
TECENTRIQ........................ 15
TECFIDERA ........................ 76
TECHLITE LANCETS ........ 63
TECHLITE PEN NEEDLE .. 63
TECHNIVIE........................... 4
TEFLARO .............................. 6
TEGRETOL ......................... 18
TEGRETOL XR ................... 18
TEKTURNA ........................ 34
TEKTURNA HCT ............... 34
TELCARE BGM .................. 63
TELCARE BLOOD
GLUCOSE KIT ................ 63
TELCARE TEST STRIPS ... 54
telmisartan ............................ 34
telmisartan-amlodipine ......... 34
telmisartan-hydrochlorothiazid
.......................................... 34
temazepam ............................ 29
TEMODAR .......................... 15
TEMOVATE ........................ 47
TEMOVATE E .................... 47
temozolomide ....................... 15
tencon ................................... 23
TENEX ................................. 34
TENIPOSIDE ....................... 15
TENIVAC (PF) .................... 79
TENORETIC 100................. 34
TENORETIC 50................... 34
TENORMIN ......................... 34
TERAZOL 3......................... 83
TERAZOL 7......................... 83
terazosin ............................... 34
terbinafine hcl ......................... 3
TERBINEX ............................ 3
terbutaline ............................. 94
terconazole ........................... 83
TERSI FOAM ...................... 39
TESSALON PERLES .......... 92
TEST N'GO BLOOD
GLUCOSE SYSTEM....... 63
TEST N'GO TEST ............... 54
TESTIM ............................... 67
TESTONE CIK .................... 67
TESTOPEL .......................... 67
testosterone ........................... 67
TESTOSTERONE................ 67
testosterone cypionate .......... 67
testosterone enanthate........... 67
TESTRED ............................ 67
tetanus toxoid,adsorbed (pf) . 79
TETANUS,DIPHTHERIA
TOX PED(PF) .................. 79
TETANUS-DIPHTHERIA
TOXOIDS-TD .................. 79
tetcaine.................................. 89
tetrabenazine ......................... 20
tetracaine hcl......................... 89
tetracaine hcl (pf).................. 89
tetracycline ........................... 11
TETRAVISC ........................ 89
TETRAVISC FORTE .......... 89
TEVETEN ............................ 34
TEXACORT......................... 47
TEXAVITE LQ .................. 105
THALOMID ......................... 16
THEO-24 .............................. 94
theochron .............................. 94
theophylline .......................... 94
thermazene............................ 39
THIOLA ............................... 49
thioridazine ........................... 29
thiotepa ................................. 16
thiothixene ............................ 29
THRIVITE RX ................... 105
thrivite-19 ........................... 105
THYMOGLOBULIN ........... 79
THYROLAR-1 ..................... 69
THYROLAR-1/2 .................. 69
THYROLAR-1/4 .................. 69
THYROLAR-2 ..................... 69
THYROLAR-3 ..................... 69
tiagabine ............................... 18
TIAZAC ............................... 34
ticlopidine ............................. 36
TIGAN.................................. 73
TIKOSYN ............................ 30
tilia fe.................................... 86
timolol maleate ............... 34, 88
TIMOPTIC ........................... 88
TIMOPTIC OCUDOSE (PF)
.......................................... 88
138
TIMOPTIC-XE..................... 88
TINDAMAX .......................... 9
tinidazole ................................9
TIROSINT ............................69
tis-u-sol ................................. 47
TITUS NEEDLE .................. 63
TIVICAY ................................ 4
TIVORBEX .......................... 25
tizanidine .............................. 21
tl gard rx ............................. 105
tl g-fol os............................. 105
tl icon .................................. 105
tl-hem 150 ........................... 105
TOBI ....................................... 9
TOBI PODHALER ................ 9
TOBRADEX ........................ 89
TOBRADEX ST ................... 89
tobramycin ............................ 87
tobramycin in 0.225 % nacl .... 9
tobramycin in 0.9 % nacl ........ 9
tobramycin sulfate .................. 9
tobramycin-dexamethasone .. 90
TOBREX .............................. 87
TODAY CONTRACEPTIVE
SPONGE........................... 83
TOFRANIL .......................... 29
TOLAK................................. 41
tolazamide............................. 68
tolbutamide ........................... 68
tolcapone............................... 19
tolmetin ................................. 25
tolterodine ............................. 95
TOPAMAX .......................... 18
TOPCARE UNIVERSAL1
LANCET .......................... 63
TOPICORT........................... 47
topiramate ............................. 18
TOPIRAMATE .................... 18
toposar .................................. 16
topotecan............................... 16
TOPROL XL ........................ 34
TORISEL .............................. 16
torsemide .............................. 34
TORSEMIDE ....................... 34
TOTECT ............................... 12
TOUJEO SOLOSTAR ......... 65
TOVIAZ ............................... 95
TRACLEER ......................... 94
TRADJENTA ....................... 68
tramadol ................................ 25
TRAMADOL ....................... 25
tramadol-acetaminophen ...... 25
trandolapril ........................... 34
trandolapril-verapamil .......... 34
tranexamic acid .............. 36, 83
TRANSDERM-SCOP .......... 73
TRANXENE T-TAB............ 29
tranylcypromine ................... 29
TRAVATAN Z .................... 89
travoprost (benzalkonium) ... 89
trazodone .............................. 29
TREANDA ........................... 16
TRECATOR ........................... 9
TRELSTAR .......................... 16
TRESIBA FLEXTOUCH U100 .................................... 65
TRESIBA FLEXTOUCH U200 .................................... 65
tretinoin ................................ 43
tretinoin (chemotherapy) ...... 16
tretinoin microspheres .......... 43
TRETIN-X ........................... 43
TRETIN-X (GEL) ................ 43
TRETIN-X CREAM KIT..... 43
TRETTEN ............................ 36
TREXALL............................ 16
TREXIMET.......................... 20
trezix ..................................... 23
TREZIX ................................ 23
TRIACETIN ......................... 45
triamcinolone acetonide 47, 50,
94
triamterene-hydrochlorothiazid
.......................................... 34
trianex ................................... 47
triazolam ............................... 29
TRIBENZOR ....................... 34
TRICARE ........................... 105
TRICARE PRENATAL
COMPLEAT .................. 105
TRICARE PRENATAL DHA
ONE................................ 105
TRICARE PRENATAL WITH
DHA ............................... 105
tricitrates ............................... 96
TRICODE AR ...................... 92
TRICODE GF ...................... 92
tricon................................... 105
TRICOR ............................... 37
triderm .................................. 47
TRIESENCE (PF) ................ 51
tri-estarylla............................ 86
TRIFERIC .......................... 105
trifluoperazine ...................... 29
trifluridine............................. 87
trigels-f forte ....................... 105
TRIGLIDE............................ 37
trihexyphenidyl ..................... 19
tri-legest fe ............................ 86
TRILEPTAL......................... 18
tri-linyah ............................... 86
TRILIPIX ............................. 37
tri-lo-estarylla ....................... 86
tri-lo-marzia .......................... 86
tri-lo-sprintec ........................ 86
trilyte with flavor packets ..... 73
trimethobenzamide ............... 73
trimethoprim ......................... 11
trimipramine ......................... 29
trinatal gt............................. 105
trinatal rx 1 ......................... 105
trinate .................................. 105
trinessa (28) .......................... 86
trinessa lo.............................. 86
TRI-NORINYL (28)............. 86
TRINTELLIX ....................... 29
TRIOSTAT ........................... 69
triphrocaps .......................... 105
TRIPLE DYE ....................... 45
tri-previfem (28) ................... 86
TRISENOX .......................... 16
tri-sprintec (28) ..................... 86
TRISTART DHA ............... 105
tri-tabs dha .......................... 105
TRIUMEQ .............................. 4
triveen-duo dha ................... 105
TRI-VI-FLOR .................... 105
tri-vit with fluoride and iron
........................................ 105
tri-vitamin with fluoride ..... 105
trivora (28) ............................ 86
TRIZIVIR ............................... 4
TROKENDI XR ................... 18
TROPAZONE CREAM ....... 41
TROPAZONE LOTION ...... 41
tropicamide ........................... 88
trospium ................................ 95
TRUE METRIX GLUCOSE
METER............................. 63
TRUE METRIX GLUCOSE
TEST STRIP ..................... 54
TRUE2GO BLOOD
TRUEDRAW LANCING
DEVICE ........................... 63
TRUEPLUS LANCETS ....... 63
TRUERESULT BLOOD
GLUCOSE SYSTM ......... 63
TRUETEST TEST STRIPS . 54
TRUETRACK BLOOD
TRUETRACK SMART
SYSTEM .......................... 64
TRUETRACK TEST............ 54
TRULICITY ......................... 68
TRUMENBA ........................ 79
TRUSOPT ............................ 89
trust natal dha ..................... 105
TRUVADA............................. 5
trypsin-balsam-castor oil ......47
TUDORZA PRESSAIR .......94
tusnel c ..................................92
TUSNEL PEDIATRIC .........92
TUSSICAPS .........................92
tussigon .................................92
TUSSIONEX PENNKINETIC
ER .....................................92
TUZISTRA XR ....................92
TWINRIX (PF) .....................79
TWYNSTA...........................34
TYBOST.................................5
TYGACIL...............................9
TYKERB ..............................16
TYLENOL-CODEINE #3 .... 23
TYLENOL-CODEINE #4 .... 23
TYSABRI .............................20
TYVASO ..............................94
TYVASO REFILL KIT ........ 94
TYVASO STARTER KIT ...94
TYZEKA ................................5
TYZINE ................................50
U
UCERIS ................................73
U-CORT ...............................41
UDAMIN SP ......................105
ULESFIA ..............................47
139
ULORIC ............................... 80
ULTICARE PEN NEEDLE . 64
ULTI-LANCE ...................... 64
ULTILET BASIC LANCETS
.......................................... 64
ULTILET CLASSIC
LANCETS ........................ 64
ULTILET LANCETS .......... 64
ULTILET PEN NEEDLE .... 64
ULTILET SAFETY
LANCETS ........................ 64
ULTIMA MONITOR ........... 64
ULTIMA TEST STRIPS ...... 54
ultimatecare one ................. 105
ultimatecare one nf ............. 105
ULTRA THIN LANCETS ... 64
ULTRA THIN PLUS
LANCETS ........................ 64
ULTRA TLC LANCETS ..... 64
ULTRACET ......................... 25
ULTRALANCE LANCETS 64
ULTRAM ............................. 25
ULTRAM ER ....................... 25
ULTRASAL-ER................... 40
ULTRA-THIN II INS PEN
NEEDLES ........................ 64
ULTRATRAK...................... 54
ULTRATRAK GLUCOSE
METER ............................ 64
ULTRATRAK ULTIMATE54,
64
ULTRAVATE ...................... 47
ULTRAVATE X .................. 47
ULTRESA ............................ 73
umecta .................................. 41
UMECTA PD ....................... 41
UNASYN ............................. 10
UNIFINE PENTIPS ............. 64
UNIFINE PENTIPS PLUS .. 64
UNILET COMFORTOUCH
LANCET .......................... 64
UNILET EXCELITE II
LANCET .......................... 64
UNILET EXCELITE
LANCET .......................... 64
UNILET GP LANCET......... 64
UNILET LANCET............... 64
UNISTIK 2 DEVICE ........... 64
UNISTIK 2 NORMAL
LANCET,DEVICE........... 64
UNISTIK 3 ........................... 64
UNISTIK 3 EXTRA LANCET
.......................................... 64
UNISTIK CZT LANCET..... 64
UNISTIK SAFETY .............. 64
UNISTIK TOUCH LANCETS
.......................................... 64
UNISTRIP1 TEST STRIP ... 54
unithroid ............................... 69
UNITUXIN .......................... 16
UNIVERSAL 1 LANCETS . 64
UPTRAVI............................. 34
ur n-c..................................... 96
URAMAXIN ........................ 41
URAMAXIN GT .................. 41
uramit mb ............................. 96
urea ....................................... 41
urea nail stick........................ 41
urea-hyaluronate sodium ...... 41
URECHOLINE .................... 95
ure-k...................................... 41
URELLE ............................... 96
uretron d-s............................. 96
URIBEL................................ 96
urimar-t ................................. 96
urin ds ................................... 96
uro-blue ................................ 96
UROCIT-K 10 ...................... 96
UROCIT-K 15 ...................... 96
UROCIT-K 5 ........................ 96
urogesic-blue ........................ 96
uro-l ...................................... 96
urolet mb............................... 96
uro-mp .................................. 96
urophen mb ........................... 96
UROQID-ACID NO.2.......... 96
UROXATRAL ..................... 95
URSO 250 ............................ 73
URSO FORTE...................... 73
ursodiol ................................. 73
uryl........................................ 96
ustell ..................................... 96
UTA ...................................... 96
UTIBRON NEOHALER ...... 95
utira-c.................................... 96
UTOPIC................................ 41
UVADEX ............................. 42
140
V
VAGIFEM ............................ 83
vaginal contraceptive foam...83
valacyclovir ............................ 5
VALCHLOR ........................ 42
VALCYTE ............................. 5
valganciclovir ......................... 5
VALIUM .............................. 29
valproate sodium .................. 18
valproic acid ......................... 18
valproic acid (as sodium salt)
.......................................... 18
valsartan ................................ 34
valsartan-hydrochlorothiazide
.......................................... 34
VALTREX ............................. 5
VANACOF CD .................... 92
VANATOL LQ .................... 23
VANCOCIN ......................... 11
vancomycin........................... 11
VANCOMYCIN IN
DEXTROSE 5 % ..............11
vandazole ..............................83
VANOS ................................47
VANOXIDE-HC .................. 43
VAQTA (PF) ........................ 80
VARIVAX (PF).................... 80
VARIZIG .............................. 80
VARUBI ............................... 73
VASCEPA ............................ 38
VASERETIC ........................ 34
VASHE WOUND THERAPY
.......................................... 47
vasolex .................................. 47
VASOSTRICT ..................... 67
VASOTEC ............................ 34
v-c forte .............................. 105
VCF CONTRACEPTIVE
FILM................................. 83
VCF CONTRACEPTIVE GEL
.......................................... 83
VECAMYL .......................... 38
VECTIBIX ........................... 16
VECTICAL .......................... 39
VEHICLE/N ......................... 42
VEHICLE/N MILD .............. 42
VELCADE ........................... 16
veletri .................................... 34
velivet triphasic regimen (28)
.......................................... 86
VELPHORO......................... 73
VELTASSA ......................... 73
VELTIN ............................... 43
vemavite-prx-2 ................... 105
VENCLEXTA ...................... 16
VENCLEXTA STARTING
PACK ............................... 16
venlafaxine ........................... 29
VENOFER ......................... 105
VENTAVIS .......................... 95
VENTOLIN HFA................. 95
VERAMYST ........................ 95
verapamil .............................. 34
VERDESO ........................... 47
verdrocet ............................... 23
VEREGEN ........................... 42
VERELAN ........................... 34
VERELAN PM .................... 34
veripred 20............................ 51
VERSACLOZ ...................... 29
VESICARE .......................... 95
vestura (28) ........................... 86
VEXOL ................................ 90
VFEND................................... 3
VFEND IV ............................. 3
VGO 20 ................................ 64
VGO 30 ................................ 64
VGO 40 ................................ 64
VIBATIV ............................. 11
VIBERZI .............................. 73
VIBRAMYCIN .................... 11
vic-forte .............................. 105
vicodin .................................. 23
vicodin es.............................. 23
vicodin hp ............................. 23
VICOPROFEN ..................... 23
VICTOZA 2-PAK ................ 68
VICTOZA 3-PAK ................ 68
VICTRELIS ........................... 5
VIDAZA............................... 16
VIDEX 2 GRAM PEDIATRIC
............................................ 5
VIDEX EC ............................. 5
VIEKIRA PAK ...................... 5
vienva ................................... 86
VIGAMOX........................... 87
VIIBRYD ............................. 29
VIMIZIM.............................. 67
VIMOVO.............................. 25
VIMPAT ............................... 18
vinate care........................... 106
vinate dha ........................... 106
VINATE DHA RF.............. 106
vinate ii ............................... 106
vinate m .............................. 106
vinate one ........................... 106
vinate ultra .......................... 106
vinblastine ............................ 16
vincasar pfs ........................... 16
vincristine ............................. 16
vinorelbine ............................ 16
VIOKACE ............................ 73
viorele (28) ........................... 86
VIRACEPT ............................ 5
VIRAMUNE .......................... 5
VIRAMUNE XR .................... 5
VIRASAL............................. 40
VIRAZOLE ............................ 5
VIREAD ................................. 5
VIROPTIC............................ 87
virt-advance ........................ 106
virt-bal dha ......................... 106
virt-c dha............................. 106
VIRT-CAPS ....................... 106
virt-care one ........................ 106
virt-gard .............................. 106
virt-nate .............................. 106
virt-nate dha ........................ 106
virt-phos 250 neutral ............ 98
virt-pn ................................. 106
virt-pn dha .......................... 106
virt-pn plus ......................... 106
VIRTPREX ........................ 106
virtrate-2 ............................... 96
virtrate-3 ............................... 96
virtrate-k ............................... 96
virt-select ............................ 106
virtussin ac............................ 92
virtussin dac.......................... 92
virt-vite ............................... 106
virt-vite gt ........................... 106
VIRT-VITE PLUS ............. 106
VISTARIL ............................ 91
VISTOGARD ....................... 12
VISUDYNE.......................... 89
vit 3 ..................................... 106
vit b complex-folic acid ...... 106
VITA-BEE WITH C........... 106
VITAFOL ........................... 106
VITAFOL FE+ (WITH
DOCUSATE) ................. 106
VITAFOL GUMMIES ....... 106
VITAFOL NANO .............. 106
VITAFOL ULTRA ............. 106
vitafol-ob ............................ 106
VITAFOL-OB+DHA ......... 106
VITAFOL-ONE ................. 106
VITAFOL-PLUS ................ 106
vitafol-pn (ud) ..................... 106
VITAL-D RX ..................... 106
VITAMAX ......................... 106
VITAMED MD ONE RX .. 106
VITAMED MD PLUS RX . 106
VITAMEDMD REDICHEW
RX................................... 106
vitamin d3 ........................... 106
vitamin k ............................... 36
vitamin k1 ............................. 36
vitamins a,c,d and fluoride . 106
VITAMINS B COMPLEX . 106
VITAPEARL ...................... 106
VITA-RESPA ..................... 106
VITEKTA ............................... 5
VITRASE ............................. 89
VITUZ .................................. 92
VIVA DHA ........................ 106
VIVELLE-DOT .................... 83
VIVITROL ........................... 25
VOGELXO ........................... 67
vol-care rx ........................... 106
vol-nate ............................... 106
vol-plus ............................... 106
vol-tab rx ............................ 106
VOLTAREN......................... 25
VOLTAREN-XR .................. 25
VONVENDI ......................... 36
VORAXAZE ........................ 12
voriconazole ........................... 3
VOSPIRE ER ....................... 95
VOTRIENT .......................... 16
VP CH ULTRA .................. 106
vp-ch plus ........................... 106
vp-ch-pnv ............................ 106
vp-era ob plus ..................... 106
vp-ggr-b6 ............................ 106
141
vp-heme ob ......................... 106
vp-heme one ....................... 107
VP-PNV-DHA ................... 107
VPRIV .................................. 67
vp-vite rx ............................ 107
VRAYLAR........................... 29
VUSION ............................... 45
vyfemla (28) ......................... 86
VYTORIN 10-10.................. 38
VYTORIN 10-20.................. 38
VYTORIN 10-40.................. 38
VYTORIN 10-80.................. 38
VYVANSE ........................... 29
W
warfarin ................................ 36
water for irrigation, sterile.... 49
WAVESENSE AMP ............ 64
WAVESENSE JAZZ ..... 54, 64
WAVESENSE PRESTO 54, 64
WELCHOL .......................... 38
WELLBUTRIN SR .............. 29
WELLBUTRIN XL.............. 29
wera (28) .............................. 86
westhroid .............................. 69
WIDE-SEAL DIAPHRAGM
.......................................... 81
WILATE............................... 36
WP THYROID ..................... 69
wymzya fe ............................ 86
X
XALATAN........................... 89
XALKORI ............................ 16
XANAX ............................... 29
XANAX XR ......................... 29
XARELTO ........................... 36
XARTEMIS XR ................... 23
XCLAIR ............................... 42
XELJANZ ............................ 81
XELJANZ XR ...................... 81
XELODA ............................. 16
XENADERM ....................... 47
XENAZINE .......................... 20
XERESE ............................... 45
XGEVA ................................ 12
XIFAXAN .............................. 9
XIGDUO XR........................ 68
XODOL 10/300 .................... 23
XODOL 5/300 ...................... 23
XODOL 7.5/300 ................... 23
XOLAIR ............................... 95
XOLEGEL............................ 45
xolox ..................................... 23
XOPENEX ........................... 95
XOPENEX CONCENTRATE
.......................................... 95
XOPENEX HFA .................. 95
XTAMPZA ER..................... 23
XTANDI............................... 16
xulane ................................... 83
XURIDEN ............................ 49
XYLOCAINE ....................... 44
XYLOCAINE-EPINEPHRINE
.......................................... 44
XYLOCAINE-MPF ............. 44
xylon 10 ................................ 23
XYNTHA ............................. 36
XYNTHA SOLOFUSE ........ 36
XYREM................................ 29
XYZAL ................................ 91
XYZBAC............................ 107
Y
YALE SPINAL NEEDLE .... 64
YASMIN (28)....................... 87
YAZ (28) .............................. 87
YERVOY ............................. 16
YODOXIN ............................. 9
YONDELIS .......................... 16
Z
zafirlukast ............................. 95
zaleplon ................................ 29
ZALTRAP ............................ 16
zamicet.................................. 24
ZANABIN ............................ 42
ZANAFLEX ......................... 21
ZANOSAR ........................... 16
ZANTAC .............................. 74
zarah ..................................... 87
ZARONTIN.......................... 18
ZARXIO ............................... 75
zatean-ch ............................. 107
zatean-pn dha ...................... 107
zatean-pn plus ..................... 107
zavara.................................. 107
ZAVESCA............................ 67
ZEBETA ............................... 34
zebutal .................................. 24
ZECUITY ............................. 20
ZEGERID ............................. 74
142
ZEGERID OTC .................... 75
ZELAPAR ............................ 19
ZELBORAF ......................... 16
ZEMAIRA ............................ 49
ZEMPLAR ........................... 67
zenatane ................................ 43
zenchent (28) ........................ 87
zenchent fe ............................ 87
zencia .................................... 43
ZENPEP ............................... 73
zenzedi .................................. 29
ZENZEDI ............................. 29
ZEPATIER ............................. 5
ZERBAXA ............................. 6
ZERIT ..................................... 5
ZESTORETIC ...................... 34
ZESTRIL .............................. 34
ZETIA................................... 38
ZETONNA ........................... 95
ZEVALIN (Y-90) ................. 16
zflex ...................................... 25
ZIAC ..................................... 34
ZIAGEN ................................. 5
ZIANA .................................. 43
zidovudine .............................. 5
ZINACEF ............................... 6
ZINACEF IN STERILE
WATER .............................. 6
ZINBRYTA .......................... 76
ZINECARD (AS HCL) ........ 12
zingiber ............................... 107
ZINGO .................................. 44
ZIOPTAN (PF) ..................... 89
ziprasidone hcl ...................... 29
ZIPSOR ................................ 25
ZIRGAN ............................... 87
ZITHRANOL ....................... 39
ZITHRANOL-RR................. 39
ZITHROMAX ........................ 6
ZMAX .................................... 7
ZOCOR................................. 38
ZODRYL AC 25 .................. 92
ZODRYL AC 30 .................. 92
ZODRYL AC 35 .................. 92
ZODRYL AC 40 .................. 92
ZODRYL AC 50 .................. 92
ZODRYL AC 60 .................. 92
ZODRYL AC 80 .................. 92
ZODRYL DAC 25 ............... 92
ZODRYL DAC 30 ............... 92
ZODRYL DAC 35 ............... 92
ZODRYL DAC 40 ............... 92
ZODRYL DAC 50 ............... 92
ZODRYL DAC 60 ............... 92
ZODRYL DAC 80 ............... 92
ZODRYL DEC 25................ 92
ZODRYL DEC 30................ 92
ZODRYL DEC 35................ 92
ZODRYL DEC 40................ 92
ZODRYL DEC 50................ 93
ZODRYL DEC 60................ 93
ZODRYL DEC 80................ 93
ZOFRAN (AS
HYDROCHLORIDE) ...... 73
ZOFRAN ODT..................... 73
ZOHYDRO ER .................... 24
ZOLADEX ........................... 16
zoledronic acid ..................... 67
zoledronic acid-mannitol-water
.......................................... 49
ZOLEDRONIC ACIDMANNITOL-WATER ..... 67
ZOLINZA ............................. 16
zolmitriptan .......................... 20
ZOLOFT ............................... 29
zolpidem ............................... 29
ZOLPIMIST ......................... 29
ZOMACTON ....................... 75
ZOMETA ............................. 67
ZOMIG ................................. 20
ZOMIG ZMT ....................... 20
ZONALON ........................... 42
ZONATUSS ......................... 93
ZONEGRAN ........................ 18
zonisamide ............................ 18
ZONTIVITY ........................ 37
ZORBTIVE .......................... 75
ZORTRESS .......................... 16
ZORVOLEX ........................ 25
ZOSTAVAX (PF) ................ 80
ZOSYN ................................. 10
ZOSYN IN DEXTROSE (ISOOSM) ................................ 10
zovia 1/35e (28) .................... 87
zovia 1/50e (28) .................... 87
ZOVIRAX ........................ 5, 45
Z-TUSS AC .......................... 93
ZUBSOLV ............................ 25
ZUPLENZ ............................ 73
ZUTRIPRO........................... 93
ZYBAN ................................ 49
ZYCLARA ........................... 76
ZYDELIG ............................. 16
ZYFLO ................................. 95
ZYFLO CR ........................... 95
ZYKADIA ............................ 16
ZYLET ................................. 90
ZYLOPRIM .......................... 80
ZYMAXID ........................... 87
ZYPREXA ............................ 29
ZYPREXA RELPREVV ......30
ZYPREXA ZYDIS ...............30
ZYTIGA ............................... 16
ZYVOX .................................. 9
143

3 Tier - ConnectiCare

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