Aetna`s Pharmacy Tier Listing

Transcription

Quality health plans & benefits
Healthier living
Financial well-being
Intelligent solutions
2015 Aetna Pharmacy Plan Drug List
Three Tier Open Commercial
(Fully Insured)
www.aetna.com
©2015 Aetna Inc.
05.05.303.1 T (7/15)
Do you have questions?
Call the toll-free number on your member ID card. Or visit
www.aetna.com/formulary for the most up-to-date information.
Dear Member:
What pharmacy benefits plan do I have?
To help you know how drugs are covered by your plan, we
are pleased to provide you with a copy of our 2015 Aetna
Pharmacy Plan Drug List.
You are enrolled in the Aetna Commercial Three Tier
Open Formulary for fully insured plans.
This guide provides helpful information about your pharmacy
benefits plan. You may want to take this guide with you when
you see your doctor to talk about what is covered under your
plan and what you can expect to pay for your medicine.
Many commonly prescribed drugs are listed in this guide. Please
remember this is not a complete list of drugs covered under your
plan. Because thousands of drugs are included in your pharmacy
benefits plan, we only list the most commonly prescribed ones.
Here’s what that means to you:
Think of tier as a level. Three Tier means you could pay three
different amounts, depending on the drug you take.
A formulary is a list of generic and brand-name drugs that your
health plan covers. An open formulary means your plan covers
most prescription drugs. But it may not cover some others.
What can I expect to pay?
With this health benefits and health insurance plan, the amount
you pay depends on the drug your doctor prescribes. It’s either
a flat fee or a percent of the prescription’s price.
What you pay falls into one of these tiers or levels:
Tier One: Generics – You pay the lowest cost for drugs in
this level.
Tier Two: Preferred Brands – You pay a slightly higher cost
for drugs in this level.
Tier Three: Non-Preferred Brands – You pay the highest cost
for drugs in this level.
To find your exact costs
Check your Plan Design and Benefits summary. This should be
in your enrollment kit.
Your pharmacy benefits plan may include a program that
encourages you to choose a generic drug over a brand-name
drug, in order to help reduce what you pay. This means that
if you fill a brand-name drug when a generic is available, that
in addition to your standard copay or coinsurance, you must
also pay the difference in cost between the brand-name and
generic drug.
For a summary of your pharmacy benefits plan, including
out-of-pocket costs, visit www.aetna.com and log in to Aetna
Navigator. Or call the toll-free number on your member ID card.
www.aetna.com/formulary
Where can I find more formulary information?
Why is the formulary subject to change?
You and your doctor can search for a drug, find out if it’s covered
and see what tier it falls under. You can also see if there are
alternatives that cost less. Make sure your doctor knows that
you pay more for two and three tier drugs. He or she can
consider this before writing a prescription.
We may add or remove drugs for certain reasons. We might
also move a drug from one coverage tier to another.
Take these steps:
1.Visit www.aetna.com/formulary. You arrive at a page that
says “Medication Search.”
2.This is where you can learn more about the types of
drug coverage reviews your drug requires; things like
precertification, step therapy or quantity limits. You will
arrive at a menu page where you can view various drug lists,
including your Aetna Pharmacy Plan Drug List and more.
How is the formulary developed?
Aetna’s Pharmacy and Therapeutics (P&T) Committee meets
regularly to review new drugs and new information about
drugs that are already on the market. It reviews available
information concerning safety, effectiveness and current use
in therapy. The P&T Committee reviews scientific evidence,
including relevant findings of federal government agencies,
pharmaceutical manufacturers, medical professional
associations, national commissions and peer-reviewed journals.
Our P&T Committee includes licensed pharmacists and doctors,
including those who are currently in practice and others who are
Aetna employees. All committee members must tell us if they
are in a situation that can create a conflict of interest or if they
have a financial stake that might affect their decisions.
Once the P&T Committee completes its clinical review, we
also consider overall value (including cost and manufacturer
rebate arrangements) and other factors before adding or
removing a drug from the formulary. Aetna Pharmacy Plan
Drug List shows you recent changes to the guide. For example,
it could show what drugs started requiring coverage reviews like
precertification, step therapy or quantity limits. Or which drugs
no longer do. The P&T Committee can make recommendations
to change the tier level of a drug or to place it on our Formulary
Exclusions List, designating it as a drug that is no longer covered.
Here are some reasons why:
•As brand-name drugs lose their patents and generic versions
become available, the brand-name may be covered at a higher
out-of-pocket cost while the generic may be covered at a lower
out-of-pocket cost.
•The Food and Drug Administration (FDA) approves many
new drugs throughout the year.
•Drugs can be withdrawn from the market or may become
available without a prescription.
Our website, www.aetna.com/formulary, reflects the most
up-to-date formulary information – so please visit it often.
Why do some drugs require prior authorization
or precertification?
This drug coverage review encourages appropriate and costeffective use of prescription drugs by allowing coverage only
when certain conditions are met.
Reasons for precertification include:
•Compliance with dosing guidelines
•Avoiding duplicate therapies
•Helping health care providers check that a drug is being
used based on generally accepted medical criteria
The precertification program is based upon current medical
findings, FDA-approved manufacturer labeling information,
and cost and manufacturer rebate arrangements.
If your plan requires precertification, you will find a list of drugs
that are subject to precertification with this guide. Please keep
the following in mind:
•Your doctor must contact Aetna to request approval of
coverage for these drugs.
•If we approve the request, we will notify your doctor. The
drug will then be covered at the applicable out-of-pocket
cost under your plan. You will also be notified of approvals
where the state requires notification to members.
If the request is denied, you and your doctor will be notified.
You can still purchase the drug, but for the full price.
Why do some drugs have quantity limits?
Saving on prescriptions
This drug coverage review limits coverage of quantities for
certain drugs. These limits help your doctor and pharmacist
check that your prescribed drug is used correctly and safely.
Here are some other tips to pay less out of pocket for your
prescription drugs:
We use medical guidelines and FDA-approved recommendations
from drug makers to set these coverage limits. The quantity limit
program includes:
•Dose Efficiency Edits – Limit coverage of prescriptions to one
dose per day for drugs that are approved for once-daily dosing.
•Maximum Daily Dose – A message is sent to the pharmacy
if a prescription is less than the minimum or higher than the
maximum allowed dose.
•Quantity Limits Over Time – Limit coverage of prescriptions
to a specific number of units in a defined amount of time.
What is step therapy?
This drug coverage review promotes the appropriate use
of equally effective but lower-cost drugs first. Prerequisite
drugs are FDA-approved and treat the same condition as
the corresponding step therapy drugs.
What is therapeutic duplication?
Therapeutic duplication means that two or more drugs of
the same type are prescribed at the same time. This can occur
when two doctors prescribe similar drugs or when your doctor
switches from one drug to another drug in the same class
without cancelling the first prescription.
It is rare that you should ever need two drugs from the same
class to treat a medical condition. Since serious side effects
may occur, we help bring such duplications to your pharmacist’s
and doctor’s attention.
Learn more about drug coverage reviews
If you have a medical need for a drug that requires precertification,
quantity limits or step therapy, your doctor can ask for a medical
exception. The list of drugs requiring precertification, quantity
limits or step therapy is subject to change. Find the most
up-to-date information at www.aetna.com/formulary.
You may be able to save with generic drugs
Generic drugs are approved by the U.S. Food and Drug
Administration (FDA) and proven to be just as safe and effective
as brand-name drugs. They contain the same active ingredients
in the same amounts as the brand-name products. The
difference is that generics may be a different color, shape or size.
When appropriate, your doctor may decide to prescribe, or allow
substitution with, a generic drug. Please talk to your doctor to
find out if a generic is right for you.
•Ask your doctor to consider prescribing generic drugs
instead of brand-name drugs.
•Ask your doctor to consider prescribing drugs that are
on the Aetna Pharmacy Plan Drug List.
•Check to see if your plan includes our mail-order pharmacy
service. Depending upon your plan, mail order may save you
money. See Aetna Rx Home Delivery® in this guide for details.
•Remind your doctor to check your plan to make sure you
get maximum coverage.
What is Aetna Rx Home Delivery?
Check your plan documents to see if your plan includes
our Aetna Rx Home Delivery mail-order pharmacy. It fills
prescriptions for maintenance medicine. This type of medicine
is used regularly, to treat conditions like arthritis, asthma,
diabetes or high cholesterol. If you need this type of drug, you
can get up to a 90-day supply, or the maximum supply allowed
by your plan, and free delivery right to your mailbox.
You also get:
•Quick, confidential service
•Free standard shipping
•Pharmacists who check all prescriptions for accuracy
and can answer questions any time
It’s easy and fast to order – choose one of these ways:
1. Mail – Get a new prescription from your doctor. Mail
your new prescription to Aetna Rx Home Delivery with
a completed order form. You can access the form online.
Visit www.aetna.com and log in to Aetna Navigator,
your secure member website. Or you can go right to
www.aetnanavigator.com. Once logged in, click the
link to “Aetna Pharmacy”.
2. F
ax – Give your doctor the Aetna Rx Home Delivery fax
number: 1-877-270-3317. Your doctor can fax in the
prescription. Make sure your doctor includes your member
ID number, your date of birth and your mailing address on
the fax cover sheet. Only a doctor may fax a prescription.
3. Phone – To help make it easy to get started, you can also
choose to use our Aetna Rx Courtesy Start SM program. Call
the toll-free number on your member ID card. Ask us to reach
out to your doctor. We can request a new 90-day prescription
on your behalf. Your doctor may need you to schedule a visit
before he or she will write you a new prescription. After we
reach out to your doctor, please allow time (up to 7 days) for
us to receive a reply. To help this process move quickly, please
alert your doctor to expect our call.
If your prescription is for a controlled medicine, a written
prescription from your doctor may be needed.
Generally, if your order is complete, you will receive your
medicine within 10-14 days from when Aetna Rx Home Delivery
receives your order. You can request expedited delivery for an
additional charge.
What is Aetna Specialty Pharmacy?
Aetna Specialty Pharmacy is Aetna’s in-house specialty
pharmacy. It can fill your prescription specialty medicine.
These types of drugs may be injected, infused or taken by
mouth. Specialty medicine often needs special storage and
handling. It must be delivered quickly. And a nurse or pharmacist
should monitor you during your treatment. Use Aetna Specialty
Pharmacy to get this medicine sent right to your mailbox.
You also get:
•Free delivery that is reliable, secure and sent anywhere
you choose
•Extra help when you need it – like injection training and
side effect monitoring
•Proactive outreach to confirm your refills
•Free standard supplies
•Nurses and pharmacists who can help you 24 hours a day,
every day
It’s easy and fast to order – choose one of these ways:
•Fax – Your doctor may fax your prescription to
1-866-FAX-ASRX (1-866-329-2779).
•Mail – You or your doctor may mail your prescription order to:
Aetna Specialty Pharmacy, 503 Sunport Lane, Orlando, FL 32809.
If you mail in your own prescription, please send it along with
a completed Patient Profile Form. To access this form, visit
www.AetnaSpecialtyRx.com and click “Specialty pharmacy:
How to enroll.”
•Phone – Your doctor may also call and speak to one
of our registered pharmacists at 1-866-782-ASRX
(1-866-782-2779) during normal business hours of
8 a.m. until 7 p.m. ET.
To transfer an existing prescription order to be filled by
Aetna Specialty Pharmacy, call toll-free at 1-866-353-1892.
Need more information?
Visit www.aetna.com/formulary or call the
appropriate toll-free number on your member ID card.
Please note that if your prescription drug benefits plan changes, the information herein may no longer apply.
A copayment is a flat fee. Coinsurance is a percentage of the rate that Aetna negotiates with the plan sponsor for covered prescriptions except as required by law
to be otherwise. Some drugs on the Preferred Drug List are subject to manufacturer rebates. Coinsurance is calculated before any rebates are subtracted. That
means it may be possible for your cost of a preferred drug to be higher than your cost of a non-preferred drug.
Health benefits and health insurance plans are offered, administered and/or underwritten by Aetna Health Inc., Aetna Health Insurance Company of New York,
Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health Inc. and/or Aetna Life Insurance Company. In
Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole financial responsibility for its own products. Aetna Pharmacy
Management refers to an internal business unit of Aetna Health Management, LLC. Aetna Specialty Pharmacy refers to Aetna Specialty Pharmacy, LLC, a subsidiary
of Aetna Inc., which is a licensed pharmacy that operates through specialty pharmacy prescription fulfillment.
Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features
and availability may vary by location and are subject to change.
SP – Drugs listed are managed by our Aetna’s Specialty Health Care Management SM nurse team. Members receive the support of this team throughout the entire
course of therapy. This team employs a “split fill” dispensing provision. This means that half of a one month’s supply of medicine is filled at a time. Split fill
dispensing allows the nurse team to offer more support, including more follow up to monitor response to treatment and potential reactions or side-effects. This
helps prevent wasted medicine and saves members money if their medicine or dose changes between fills. This list is not all-inclusive and is subject to change.
Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna’s Preferred Drug List. Rebates do not reduce the amount a
member pays the pharmacy for covered prescriptions. Information is subject to change. For more information about Aetna plans, refer to www.aetna.com.
The drugs on the Preferred Drug List, Formulary Exclusions, Precertification, Quantity Limit and Step Therapy Lists are subject to change. The quantity limits and
step therapy drug coverage review programs are not available in all service areas. For example, step therapy programs do not apply to fully-insured members in
Indiana. Step therapy does not apply to fully-insured members in New Jersey. However, these programs are available to self-funded plans.
In accordance with state law, commercial fully-insured members in Louisiana and Texas (except Federal Employee Health Benefit Plan members) who are receiving
coverage for medications that are added or removed from the Preferred Drug List, Precertification, Quantity Limits or Step-Therapy Lists during the plan year will
continue to have those medications covered at the same benefit level until their plan’s renewal date. In Texas, precertification approval is known as “pre-service
utilization review.” It is not “verification” as defined by Texas law.
In accordance with state law, fully-insured Commercial California HMO members (except Federal Employee Health Benefit Plan members) who are receiving
coverage for medications that are added to the Precertification or Step-therapy Lists will continue to have those medications covered, for as long as the treating
physician continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee’s medical
condition. In accordance with state law, fully-insured Commercial Connecticut PPO members (except Federal Employee Health Benefit Plan members) who are
receiving coverage for medications that are added to the Precertification or Step-therapy Lists will continue to have those medications covered for as long as the
treating physician prescribes them, provided the drug is medically necessary and more medically beneficial than other covered drugs. Nothing in this section shall
preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this
section be construed to prohibit generic drug substitutions.
This material is for information only. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. See plan
documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are
subject to change. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide
care or guarantee access to health services. Information is subject to change. For more information about Aetna plans, refer to www.aetna.com.
www.aetna.com
©2015 Aetna Inc.
05.05.303.1 T (7/15)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
Table of Contents
Contents
of
Table
*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* ............................................................................................................................. 3
*ALTERNATIVE MEDICINES* ...................................................................................................................................................................................................................................... 5
*AMEBICIDES* ....................................................................................................................................................................................................................................................................................... 5
*AMINOGLYCOSIDES* ............................................................................................................................................................................................................................................................. 5
*ANALGESICS - ANTI-INFLAMMATORY* ............................................................................................................................................................................................... 5
*ANALGESICS - NONNARCOTIC* .......................................................................................................................................................................................................................... 7
*ANALGESICS - OPIOID* ....................................................................................................................................................................................................................................................... 8
*ANDROGENS-ANABOLIC* .......................................................................................................................................................................................................................................... 11
*ANORECTAL AGENTS* ..................................................................................................................................................................................................................................................... 12
*ANTHELMINTICS* .................................................................................................................................................................................................................................................................... 13
*ANTIANGINAL AGENTS* ............................................................................................................................................................................................................................................. 13
*ANTIANXIETY AGENTS* ............................................................................................................................................................................................................................................... 14
*ANTIARRHYTHMICS* ........................................................................................................................................................................................................................................................ 14
*ANTIASTHMATIC AND BRONCHODILATOR AGENTS* ............................................................................................................................................ 15
*ANTICOAGULANTS* ............................................................................................................................................................................................................................................................. 17
*ANTICONVULSANTS* ......................................................................................................................................................................................................................................................... 17
*ANTIDEPRESSANTS* ............................................................................................................................................................................................................................................................ 20
*ANTIDIABETICS* ........................................................................................................................................................................................................................................................................ 22
*ANTIDIARRHEALS* ............................................................................................................................................................................................................................................................... 26
*ANTIDOTES* ....................................................................................................................................................................................................................................................................................... 26
*ANTIEMETICS* ............................................................................................................................................................................................................................................................................... 27
*ANTIFUNGALS* ............................................................................................................................................................................................................................................................................ 27
*ANTIHISTAMINES* .................................................................................................................................................................................................................................................................. 28
*ANTIHYPERLIPIDEMICS* ............................................................................................................................................................................................................................................ 29
*ANTIHYPERTENSIVES* .................................................................................................................................................................................................................................................... 30
*ANTI-INFECTIVE AGENTS - MISC.* .............................................................................................................................................................................................................. 34
*ANTIMALARIALS* .................................................................................................................................................................................................................................................................... 35
*ANTIMYASTHENIC/CHOLINERGIC AGENTS* .......................................................................................................................................................................... 35
*ANTIMYCOBACTERIAL AGENTS* ................................................................................................................................................................................................................. 35
*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* .................................................................................................................................................. 36
*ANTIPARKINSON AGENTS* ..................................................................................................................................................................................................................................... 38
*ANTIPSYCHOTICS/ANTIMANIC AGENTS* ....................................................................................................................................................................................... 39
*ANTISEPTICS & DISINFECTANTS* ................................................................................................................................................................................................................ 41
*ANTIVIRALS* .................................................................................................................................................................................................................................................................................... 41
*ASSORTED CLASSES* ........................................................................................................................................................................................................................................................... 44
*BETA BLOCKERS* ...................................................................................................................................................................................................................................................................... 45
*BIOLOGICALS MISC* ............................................................................................................................................................................................................................................................ 46
*CALCIUM CHANNEL BLOCKERS* ................................................................................................................................................................................................................. 46
*CARDIOTONICS* ......................................................................................................................................................................................................................................................................... 47
*CARDIOVASCULAR AGENTS - MISC.* .................................................................................................................................................................................................... 47
*CEPHALOSPORINS* ................................................................................................................................................................................................................................................................ 48
*CONTRACEPTIVES* ................................................................................................................................................................................................................................................................ 48
*CORTICOSTEROIDS* ............................................................................................................................................................................................................................................................. 53
*COUGH/COLD/ALLERGY* ........................................................................................................................................................................................................................................... 54
*DERMATOLOGICALS* ....................................................................................................................................................................................................................................................... 56
*DIAGNOSTIC PRODUCTS* .......................................................................................................................................................................................................................................... 67
*DIGESTIVE AIDS* ....................................................................................................................................................................................................................................................................... 75
*DIURETICS* ......................................................................................................................................................................................................................................................................................... 75
*ENDOCRINE AND METABOLIC AGENTS - MISC.* .............................................................................................................................................................. 76
*ESTROGENS* ...................................................................................................................................................................................................................................................................................... 79
1
Contents
of
Table
*FLUOROQUINOLONES* .................................................................................................................................................................................................................................................. 80
*GASTROINTESTINAL AGENTS - MISC.* ............................................................................................................................................................................................... 80
*GENERAL ANESTHETICS* .......................................................................................................................................................................................................................................... 82
*GENITOURINARY AGENTS - MISCELLANEOUS* ................................................................................................................................................................ 82
*GOUT AGENTS* ............................................................................................................................................................................................................................................................................. 83
*HEMATOLOGICAL AGENTS - MISC.* ........................................................................................................................................................................................................ 83
*HEMATOPOIETIC AGENTS* ..................................................................................................................................................................................................................................... 85
*HEMOSTATICS* ............................................................................................................................................................................................................................................................................. 88
*HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS* ................................................................................................................................................ 88
*LAXATIVES* ........................................................................................................................................................................................................................................................................................ 89
*MACROLIDES* ................................................................................................................................................................................................................................................................................ 89
*MEDICAL DEVICES* .............................................................................................................................................................................................................................................................. 90
*MIGRAINE PRODUCTS* ............................................................................................................................................................................................................................................... 115
*MINERALS & ELECTROLYTES* ....................................................................................................................................................................................................................... 116
*MOUTH/THROAT/DENTAL AGENTS* ................................................................................................................................................................................................... 118
*MULTIVITAMINS* ................................................................................................................................................................................................................................................................. 119
*MUSCULOSKELETAL THERAPY AGENTS* ................................................................................................................................................................................. 126
*NASAL AGENTS - SYSTEMIC AND TOPICAL* .......................................................................................................................................................................... 127
*NEUROMUSCULAR AGENTS* ........................................................................................................................................................................................................................... 128
*OPHTHALMIC AGENTS* ............................................................................................................................................................................................................................................. 128
*OTIC AGENTS* ............................................................................................................................................................................................................................................................................. 133
*OXYTOCICS* .................................................................................................................................................................................................................................................................................... 134
*PASSIVE IMMUNIZING AGENTS* ................................................................................................................................................................................................................ 134
*PENICILLINS* ................................................................................................................................................................................................................................................................................ 135
*PHARMACEUTICAL ADJUVANTS* ........................................................................................................................................................................................................... 135
*PROGESTINS* ................................................................................................................................................................................................................................................................................ 135
*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* ....................................................................................................... 135
*RESPIRATORY AGENTS - MISC.* .................................................................................................................................................................................................................. 137
*TETRACYCLINES* ................................................................................................................................................................................................................................................................. 137
*THYROID AGENTS* ............................................................................................................................................................................................................................................................ 138
*ULCER DRUGS* ......................................................................................................................................................................................................................................................................... 139
*URINARY ANTI-INFECTIVES* .......................................................................................................................................................................................................................... 141
*URINARY ANTISPASMODICS* ......................................................................................................................................................................................................................... 142
*VAGINAL PRODUCTS* ................................................................................................................................................................................................................................................... 142
*VASOPRESSORS* ....................................................................................................................................................................................................................................................................... 143
*VITAMINS* ......................................................................................................................................................................................................................................................................................... 143
2
lowercase italics = Generic drugs
UPPERCASE = Brand name drugs
Drug Name
Drug Status
CE = Copay Exception:
Available to some
members at no cost with a
prescription from your
provider when obtained
at an in-network
pharmacy. Certain
limitations may apply.
NC = Not Covered
NC = Not Covered
NF = Non Formulary
Tier 1 = Generic
Tier 2 = Preferred Brand
Tier 3 = Non Preferred
Brand
Drug Status
Drug Details
# = Brand-name drug expected to
become available generically in the
near future
LGC = Lowest Generic Copay
Applies
N1 = Step Therapy Not Applicable
in NJ
PA = Prior Authorization Required
QL = Quantity Limit Applies
SF = Split Fill Applies
ST = Step Therapy Applies
Drug Details
*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/
ANOREXIANTS*
ADDERALL ORAL TABLET 10 MG, 12.5 MG,
15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG
Tier 3
PA; ST; N1; QL
ADDERALL XR
Tier 3
PA; ST; N1; QL
amphetamine-dextroamphet er
Tier 1
QL
amphetamine-dextroamphetamine oral tablet 10 mg,
12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg
Tier 1
QL
APTENSIO XR
Tier 3
PA; ST; QL
CAFCIT ORAL
Tier 3
caffeine citrate oral
Tier 1
clonidine hcl er
Tier 1
PA; QL
CONCERTA ORAL TABLET
EXTENDEDRELEASE* 18 MG, 27 MG, 36 MG,
54 MG
Tier 3
PA; ST; N1; QL
DAYTRANA
Tier 3
PA; ST; N1; #; QL
DESOXYN
Tier 3
PA; ST; N1; QL
(Updated 07/01/15)
3
Drug Name
Drug Status
Drug Details
DEXEDRINE ORAL CAPSULE EXTENDED
RELEASE 24 HOUR
Tier 3
PA; ST; N1; QL
dexmethylphenidate hcl
Tier 1
QL
dexmethylphenidate hcl er
Tier 1
QL
dextroamphetamine sulfate er
Tier 1
QL
dextroamphetamine sulfate oral solution
Tier 1
QL
dextroamphetamine sulfate oral tablet
Tier 1
PA; QL
EVEKEO
Tier 3
PA; ST; QL
FOCALIN
Tier 3
PA; ST; N1; QL
FOCALIN XR
Tier 3
PA; ST; N1; #; QL
guanfacine hcl er oral tablet extended release 24 hr*
1 mg
Tier 1
INTUNIV
Tier 3
PA; ST; N1; #; QL
KAPVAY ORAL TABLET EXTENDED
RELEASE 12 HR*
Tier 3
PA; ST; N1; QL
METADATE CD
Tier 3
PA; ST; N1; QL
METADATE ER
Tier 1
QL
methamphetamine hcl
Tier 1
QL
METHYLIN ER
Tier 1
QL
METHYLIN ORAL SOLUTION 10 MG/5ML, 5
MG/5ML
Tier 3
PA; ST; N1; QL
METHYLIN ORAL TABLET
Tier 1
QL
METHYLIN ORAL TABLET CHEWABLE
Tier 3
PA; ST; N1; QL
methylphenidate hcl er (cd)
Tier 1
QL
methylphenidate hcl er (la) oral capsule extended
release 24 hour 20 mg, 30 mg, 40 mg
Tier 1
QL
methylphenidate hcl er oral tablet extendedrelease*
18 mg, 20 mg, 27 mg, 36 mg, 54 mg
Tier 1
QL
methylphenidate hcl oral solution 10 mg/5ml, 5
mg/5ml
Tier 1
QL
methylphenidate hcl oral tablet
Tier 1
QL
methylphenidate hcl oral tablet chewable
Tier 1
QL
modafinil
Tier 1
PA; QL
NUVIGIL ORAL TABLET 150 MG, 200 MG,
250 MG, 50 MG
Tier 3
PA; QL
PROCENTRA
Tier 3
PA; ST; N1; QL
PROVIGIL
Tier 3
PA; QL
QUILLIVANT XR
Tier 3
PA; ST; N1; QL
RITALIN
Tier 3
PA; ST; N1; QL
(Updated 07/01/15)
4
Drug Name
Drug Status
Drug Details
RITALIN LA ORAL CAPSULE EXTENDED
RELEASE 24 HOUR 10 MG, 20 MG, 30 MG, 40
MG
Tier 3
PA; ST; N1; QL
RITALIN SR
Tier 3
PA; ST; N1; QL
STRATTERA ORAL CAPSULE 10 MG, 100
MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG
Tier 2
QL
VYVANSE
Tier 2
QL
ZENZEDI ORAL TABLET 10 MG, 5 MG
Tier 1
PA; QL
ZENZEDI ORAL TABLET 15 MG
Tier 3
PA; ST; QL
ZENZEDI ORAL TABLET 2.5 MG, 20 MG, 30
MG, 7.5 MG
Tier 3
PA; ST; N1; QL
*ALTERNATIVE MEDICINES*
QUINZYME
Tier 3
*AMEBICIDES*
YODOXIN
Tier 3
*AMINOGLYCOSIDES*
BETHKIS
Tier 3
neo-fradin
Tier 3
neomycin sulfate oral
Tier 1
paromomycin sulfate oral
Tier 1
TOBI
Tier 3
TOBI PODHALER
Tier 2
tobramycin inhalation
Tier 1
*ANALGESICS - ANTI-INFLAMMATORY*
ACTEMRA SUBCUTANEOUS*
Tier 3
PA
ANAPROX
Tier 3
ANAPROX DS
Tier 3
ARCALYST
Tier 3
ARTHROTEC
Tier 3
CATAFLAM
Tier 3
CELEBREX ORAL CAPSULE 100 MG, 200
MG, 400 MG, 50 MG
Tier 3
ST; #; QL
celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50
mg
Tier 3
PA; ST; QL
DAYPRO
Tier 3
diclofenac potassium
Tier 1
diclofenac sodium er
Tier 3
diclofenac sodium oral tablet delayed release 25 mg,
50 mg
Tier 1
diclofenac sodium oral tablet delayed release 75 mg
Tier 1
PA
LGC
(Updated 07/01/15)
5
Drug Name
Drug Status
Drug Details
diclofenac-misoprostol
Tier 1
DUEXIS
Tier 3
EC-NAPROSYN
Tier 3
ENBREL SUBCUTANEOUS* KIT
Tier 2
etodolac er
Tier 3
etodolac oral
Tier 1
FELDENE
Tier 3
fenoprofen calcium oral capsule
Tier 1
flurbiprofen oral
Tier 1
HUMIRA
Tier 2
PA
HUMIRA PEDIATRIC CROHNS START
Tier 2
PA
HUMIRA PEN
Tier 2
PA
HUMIRA PEN-CROHNS STARTER
Tier 2
PA
HUMIRA PEN-PSORIASIS STARTER
Tier 2
PA
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
Tier 1
LGC
ILARIS
Tier 2
PA
INDOCIN
Tier 3
INDOCIN ORAL
Tier 2
indomethacin er
Tier 1
indomethacin oral
Tier 1
ketoprofen er
Tier 3
ketoprofen oral
Tier 1
ketorolac tromethamine oral
Tier 1
QL
leflunomide oral
Tier 1
PA
mefenamic acid oral
Tier 3
MELOXICAM COMFORT PAC
Tier 3
meloxicam oral tablet
Tier 1
MOBIC
Tier 3
nabumetone oral
Tier 3
NALFON ORAL CAPSULE 400 MG
Tier 3
NAPRELAN ORAL TABLET EXTENDED
RELEASE 24 HR* 375 MG, 500 MG, 750 MG
Tier 3
NAPROSYN
Tier 3
naproxen dr
Tier 1
naproxen oral suspension
Tier 1
naproxen oral tablet
Tier 1
naproxen sodium er
Tier 1
naproxen sodium oral tablet 275 mg
Tier 1
ST; N1; QL
LGC
LGC
naproxen sodium oral tablet 550 mg
Tier 1
LGC
(Updated 07/01/15)
6
Drug Name
Drug Status
Drug Details
OTEZLA
Tier 3
OTREXUP
Tier 3
oxaprozin
Tier 3
piroxicam oral
Tier 1
PONSTEL
Tier 3
RASUVO
Tier 3
RHEUMATREX
Tier 3
RIDAURA
Tier 3
SIMPONI
Tier 3
PA; QL
SPRIX
Tier 3
QL
sulindac oral
Tier 1
TIVORBEX
Tier 3
tolmetin sodium oral capsule
Tier 3
tolmetin sodium oral tablet 200 mg
Tier 3
VIMOVO
Tier 3
VOLTAREN-XR
Tier 3
XELJANZ
Tier 3
ZIPSOR
Tier 3
ZORVOLEX
Tier 3
PA; ST; N1
PA; ST
QL
ST; N1; QL
PA; QL
ST; N1; QL
*ANALGESICS - NONNARCOTIC*
ALAGESIC LQ
Tier 3
anolor 300
Tier 1
aspirin oral tablet 325 mg
CE
aspirin oral tablet chewable
CE
aspirin oral tablet delayed release 325 mg, 81 mg
CE
BUPAP ORAL TABLET 50-300 MG
Tier 3
butalbital-acetaminophen
Tier 1
butalbital-apap-caffeine oral capsule
Tier 1
butalbital-apap-caffeine oral tablet 50-325-40 mg
Tier 1
butalbital-asa-caffeine
Tier 1
CAPACET
Tier 1
choline & mag trisalicylate oral tablet 1000 mg
Tier 1
choline-mag trisalicylate
Tier 1
diflunisal oral
Tier 1
duraxin
Tier 1
ED-FLEX
Tier 1
EQUAGESIC
Tier 3
ESGIC ORAL TABLET
Tier 3
(Updated 07/01/15)
7
Drug Name
Drug Status
FIORICET
Tier 3
FIORINAL
Tier 3
margesic
Tier 1
marten-tab
Tier 1
MINIPRIN LOW DOSE
Drug Details
CE
MST 600
Tier 3
ORBIVAN CF
Tier 3
PRIALT
Tier 3
repan
Tier 1
salsalate oral
Tier 1
ST JOSEPH ASPIRIN ORAL TABLET
DELAYED RELEASE
CE
TENCON ORAL TABLET 50-325 MG
Tier 1
ZEBUTAL ORAL CAPSULE 50-325-40 MG
Tier 1
*ANALGESICS - OPIOID*
ABSTRAL
Tier 3
PA; ST; N1; QL
acetaminophen-codeine
Tier 1
acetaminophen-codeine #2
Tier 1
Tier 1
Tier 1
ACTIQ BUCCAL LOLLIPOP 1200 MCG, 1600
MCG, 400 MCG, 600 MCG, 800 MCG
Tier 3
ASCOMP-CODEINE
Tier 1
AVINZA
Tier 3
PA; ST; N1; QL
BUNAVAIL BUCCAL FILM 2.1-0.3 MG, 4.2-0.7
MG, 6.3-1 MG
Tier 3
PA; ST; QL
buprenorphine hcl sublingual tablet sublingual 2 mg,
8 mg
Tier 1
PA; QL
buprenorphine hcl-naloxone hcl
Tier 1
PA; QL
butalbital compound/codeine
Tier 1
butalbital-apap-caff-cod
Tier 1
butalbital-asa-caff-codeine
Tier 1
butorphanol tartrate nasal
Tier 1
QL
BUTRANS
Tier 2
QL
CAPITAL/CODEINE
Tier 2
CONZIP
Tier 3
DEMEROL ORAL
Tier 3
DILAUDID ORAL
Tier 3
DOLOPHINE ORAL TABLET 5 MG
Tier 3
PA; ST; N1; QL
QL
QL
(Updated 07/01/15)
8
Drug Name
Drug Status
Drug Details
DURAGESIC-100
Tier 3
PA; QL
DURAGESIC-12
Tier 3
PA; QL
DURAGESIC-25
Tier 3
PA; QL
DURAGESIC-50
Tier 3
PA; QL
DURAGESIC-75
Tier 3
PA; QL
EMBEDA
Tier 3
PA; ST; QL
ENDOCET ORAL TABLET 10-325 MG, 5-325
MG, 7.5-325 MG
Tier 1
ENDODAN
Tier 1
EXALGO ORAL 12 MG, 16 MG, 32 MG, 8 MG
Tier 3
ST; N1; QL
fentanyl
Tier 1
QL
fentanyl citrate buccal
Tier 1
PA; QL
FENTORA
Tier 3
PA; ST; N1; QL
FIORICET/CODEINE ORAL CAPSULE
50-300-40-30 MG
Tier 3
FIORINAL/CODEINE #3
Tier 3
HYCET
Tier 3
hydrocodone-acetaminophen oral solution 2.5-108
mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml
Tier 1
hydrocodone-acetaminophen oral tablet 10-300 mg,
10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325
mg
Tier 1
hydrocodone-ibuprofen
Tier 1
hydromorphone hcl oral
Tier 1
HYSINGLA ER
Tier 3
IBUDONE ORAL TABLET 10-200 MG
Tier 3
IBUDONE ORAL TABLET 5-200 MG
Tier 1
KADIAN
Tier 3
PA; ST; N1; QL
LAZANDA
Tier 3
PA; ST; N1; QL
LORCET
Tier 1
LORCET HD
Tier 1
LORTAB ORAL ELIXIR 10-300 MG/15ML
Tier 3
LORTAB ORAL TABLET 10-325 MG, 5-325
MG, 7.5-325 MG
Tier 1
meperidine hcl oral tablet
Tier 1
meperitab
Tier 1
METHADONE HCL INTENSOL
Tier 1
methadone hcl oral concentrate
Tier 1
methadone hcl oral solution
Tier 1
methadone hcl oral tablet
Tier 1
PA; ST; QL
QL
(Updated 07/01/15)
9
Drug Name
Drug Status
Drug Details
methadone hcl oral tablet soluble
Tier 1
QL
METHADOSE ORAL CONCENTRATE
Tier 3
METHADOSE ORAL TABLET
Tier 1
QL
METHADOSE ORAL TABLET SOLUBLE
Tier 1
QL
METHADOSE SUGAR-FREE
Tier 3
morphine sulfate (concentrate)
Tier 1
morphine sulfate (pf) injection
Tier 1
morphine sulfate (pf) intravenous* solution 10
mg/ml, 15 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml
Tier 1
morphine sulfate er oral capsule extended release 24
hour
Tier 1
QL
morphine sulfate er oral tablet extendedrelease*
Tier 1
QL
morphine sulfate injection
Tier 1
morphine sulfate intravenous* solution 1 mg/ml, 150
mg/30ml, 25 mg/ml, 50 mg/ml
Tier 1
morphine sulfate oral solution
Tier 1
MS CONTIN
Tier 3
NORCO
Tier 3
NUCYNTA
Tier 3
ST; N1; QL
NUCYNTA ER
Tier 3
PA; ST; N1; QL
OPANA ER ORAL
Tier 2
QL
OPANA ORAL
Tier 3
ST; N1
OXECTA
Tier 3
oxycodone hcl er
Tier 1
oxycodone hcl oral
Tier 1
oxycodone-acetaminophen oral tablet 10-325 mg,
2.5-325 mg, 5-325 mg, 7.5-325 mg
Tier 1
oxycodone-aspirin
Tier 1
oxycodone-ibuprofen
Tier 1
QL
OXYCONTIN
Tier 3
PA; ST; N1; QL
oxymorphone hcl
Tier 1
oxymorphone hcl er
Tier 1
PERCOCET ORAL TABLET 10-325 MG, 2.5-325
MG, 5-325 MG, 7.5-325 MG
Tier 3
PERCODAN
Tier 3
PRIMLEV
Tier 3
REPREXAIN ORAL TABLET 10-200 MG
Tier 1
REPREXAIN ORAL TABLET 2.5-200 MG,
5-200 MG
Tier 3
ROXICET ORAL SOLUTION
Tier 2
QL
QL
(Updated 07/01/15)
10
Drug Name
Drug Status
Drug Details
ROXICET ORAL TABLET 5-325 MG
Tier 1
ROXICODONE
Tier 3
SUBOXONE SUBLINGUAL FILM 12-3 MG,
2-0.5 MG, 4-1 MG, 8-2 MG
Tier 3
PA; QL
SUBOXONE SUBLINGUAL TABLET
SUBLINGUAL
Tier 3
PA; QL
SUBSYS SUBLINGUAL LIQUID† 100 MCG,
1200 (600 X 2) MCG, 1600 (800 X 2) MCG, 200
MCG, 400 MCG, 600 MCG, 800 MCG
Tier 3
PA; ST; N1; QL
SYNALGOS-DC
Tier 3
tramadol hcl er (biphasic)
Tier 1
QL
tramadol hcl er oral tablet extended release 24 hr*
Tier 1
QL
tramadol hcl oral
Tier 1
tramadol-acetaminophen
Tier 1
TREZIX ORAL CAPSULE 320.5-30-16 MG
Tier 3
TREZIX ORAL CAPSULE 356.4-30-16 MG
Tier 3
TYLENOL WITH CODEINE #3
Tier 3
Tier 3
ULTRACET
Tier 3
ULTRAM
Tier 3
ULTRAM ER
Tier 3
VICODIN ES ORAL TABLET 7.5-300 MG
Tier 1
VICODIN HP ORAL TABLET 10-300 MG
Tier 1
VICODIN ORAL TABLET 5-300 MG
Tier 1
VICOPROFEN
Tier 3
XARTEMIS XR
Tier 3
XODOL
Tier 3
ZAMICET
Tier 3
ZOHYDRO ER
Tier 3
ZOLVIT
Tier 3
ZUBSOLV SUBLINGUAL TABLET
SUBLINGUAL 1.4-0.36 MG, 5.7-1.4 MG
Tier 3
PA; N1; QL
ZUBSOLV SUBLINGUAL TABLET
SUBLINGUAL 8.6-2.1 MG
Tier 3
PA; QL
QL
QL
PA; ST; QL
*ANDROGENS-ANABOLIC*
ANADROL-50
Tier 3
ANDROGEL PUMP TRANSDERMAL 12.5
MG/ACT (1%)
Tier 2
PA; #; QL
ANDROGEL PUMP TRANSDERMAL 20.25
MG/ACT (1.62%)
Tier 2
PA; QL
(Updated 07/01/15)
11
Drug Name
Drug Status
Drug Details
ANDROGEL TRANSDERMAL 20.25
MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%)
Tier 2
PA; QL
ANDROGEL TRANSDERMAL 25 MG/2.5GM
(1%), 50 MG/5GM (1%)
Tier 2
PA; #; QL
ANDROID
Tier 2
ANDROXY
Tier 1
AXIRON
Tier 3
danazol oral
Tier 1
FORTESTA
Tier 3
methitest
Tier 2
NATESTO
Tier 3
OXANDRIN
Tier 3
oxandrolone oral
Tier 1
STRIANT
Tier 3
PA; ST; N1; QL
TESTIM
Tier 2
PA; QL
testosterone transdermal 10 mg/act (2%)
Tier 1
QL
testosterone transdermal 12.5 mg/act (1%), 50
mg/5gm (1%)
Tier 3
PA; ST; N1; QL
testosterone transdermal 25 mg/2.5gm (1%)
Tier 3
PA; ST; QL
TESTRED
Tier 3
VOGELXO
Tier 3
PA; ST; N1; QL
VOGELXO PUMP
Tier 3
PA; ST; N1; QL
PA; ST; N1; QL
PA; ST; N1; QL
PA; ST; QL
*ANORECTAL AGENTS*
ANALPRAM-HC LOTION
Tier 3
anucort-hc
Tier 1
ANUSOL-HC CREAM
Tier 3
COLOCORT
Tier 1
CORTENEMA
Tier 3
CORTIFOAM
Tier 3
grx hicort 25
Tier 1
hemorrhoidal-hc suppository
Tier 1
HEMRIL-30
Tier 1
hydrocortisone ace-pramoxine cream
Tier 1
hydrocortisone acetate suppository
Tier 1
hydrocortisone enema
Tier 1
LIDAZONE HC
Tier 1
lidocaine-hydrocortisone ace cream
Tier 1
lidocaine-hydrocortisone ace kit 3-0.5 %, 3-1 %,
3-2.5 %
Tier 1
(Updated 07/01/15)
12
Drug Name
Drug Status
pramcort
Tier 1
PROCORT
Tier 3
PROCTOCARE-HC
Tier 1
PROCTOCREAM HC
Tier 1
PROCTOFOAM HC
Tier 3
PROCTO-PAK
Tier 1
PROCTOSOL HC
Tier 1
PROCTOZONE-HC
Tier 1
rectacort-hc
Tier 1
RECTIV
Tier 3
UCERIS
Tier 3
Drug Details
ST; QL
*ANTHELMINTICS*
ALBENZA
Tier 3
BILTRICIDE
Tier 3
ivermectin oral
Tier 1
STROMECTOL
Tier 3
*ANTIANGINAL AGENTS*
DILATRATE-SR
Tier 3
IMDUR
Tier 3
ISOCHRON
Tier 1
isoditrate er
Tier 1
ISORDIL TITRADOSE
Tier 3
isosorbide dinitrate er
Tier 1
isosorbide dinitrate oral tablet 10 mg, 20 mg, 5 mg
Tier 1
isosorbide mononitrate
Tier 1
isosorbide mononitrate er
Tier 1
MINITRAN
Tier 1
NITRO-BID
Tier 3
NITRO-DUR
Tier 3
nitroglycerin er
Tier 1
nitroglycerin transdermal
Tier 1
nitroglycerin translingual aerosol, solution
Tier 3
nitroglycerin translingual solution
Tier 1
NITROLINGUAL
Tier 3
NITROMIST
Tier 3
NITROSTAT
Tier 2
NITRO-TIME
Tier 1
RANEXA ORAL TABLET EXTENDED
Tier 2
N1; QL
RELEASE 12 HR* 1000 MG, 500 MG
(Updated 07/01/15)
13
Drug Name
Drug Status
Drug Details
*ANTIANXIETY AGENTS*
alprazolam er
Tier 1
ALPRAZOLAM INTENSOL
Tier 3
alprazolam oral
Tier 1
alprazolam xr
Tier 1
ATIVAN ORAL
Tier 3
buspirone hcl oral tablet 10 mg, 5 mg
Tier 1
buspirone hcl oral tablet 15 mg, 30 mg, 7.5 mg
Tier 1
chlordiazepoxide hcl
Tier 1
clorazepate dipotassium
Tier 1
DIAZEPAM INTENSOL
Tier 3
diazepam oral tablet
Tier 1
hydroxyzine hcl oral solution
Tier 1
hydroxyzine hcl oral syrup
Tier 1
hydroxyzine hcl oral tablet
Tier 1
hydroxyzine pamoate oral capsule 25 mg, 50 mg
Tier 1
LORAZEPAM INTENSOL
Tier 3
lorazepam oral tablet
Tier 1
meprobamate
Tier 1
NIRAVAM
Tier 3
oxazepam
Tier 1
TRANXENE-T
Tier 3
VALIUM
Tier 3
VISTARIL
Tier 3
XANAX
Tier 3
XANAX XR
Tier 3
QL
QL
LGC
LGC
QL
*ANTIARRHYTHMICS*
amiodarone hcl oral
Tier 1
CORDARONE
Tier 3
disopyramide phosphate oral
Tier 1
flecainide acetate
Tier 1
mexiletine hcl oral
Tier 1
MULTAQ
Tier 2
NORPACE
Tier 3
NORPACE CR
Tier 3
PACERONE
Tier 1
propafenone hcl
Tier 1
propafenone hcl er
Tier 1
(Updated 07/01/15)
14
Drug Name
Drug Status
quinidine gluconate er
Tier 1
quinidine sulfate oral
Tier 1
RYTHMOL
Tier 3
RYTHMOL SR
Tier 3
TIKOSYN
Tier 3
Drug Details
*ANTIASTHMATIC AND
BRONCHODILATOR AGENTS*
ACCOLATE
Tier 3
ADVAIR DISKUS
Tier 3
PA; ST; N1; QL
ADVAIR HFA
Tier 3
PA; ST; N1; QL
AEROSPAN
Tier 3
ST; N1
albuterol sulfate er
Tier 1
albuterol sulfate inhalation
Tier 1
albuterol sulfate oral
Tier 1
ALVESCO
Tier 3
ST; N1
ANORO ELLIPTA
Tier 3
PA; ST; N1; QL
ARCAPTA NEOHALER
Tier 3
PA; ST; QL
ARNUITY ELLIPTA
Tier 3
PA; ST; QL
ASMANEX 120 METERED DOSES
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
ASMANEX HFA
Tier 2
ATROVENT HFA
Tier 3
BREO ELLIPTA INHALATION AEROSOL
POWDER, BREATH ACTIVATED 100-25
MCG/INH
Tier 3
PA; ST; N1; QL
BROVANA
Tier 3
PA; ST; N1; QL
budesonide inhalation
Tier 1
PA
COMBIVENT RESPIMAT
Tier 2
cromolyn sodium inhalation
Tier 1
DALIRESP
Tier 3
DIFIL-G FORTE
Tier 1
DULERA
Tier 2
DUONEB
Tier 3
ELIXOPHYLLIN
Tier 3
epinephrine hcl injection
Tier 1
epinephrine hcl injection solution 1 mg/ml
Tier 1
PA
QL
(Updated 07/01/15)
15
Drug Name
Drug Status
Drug Details
FLOVENT DISKUS
Tier 3
ST; N1
FLOVENT HFA
Tier 3
ST; N1
FORADIL AEROLIZER
Tier 2
QL
INCRUSE ELLIPTA
Tier 3
PA; ST; QL
ipratropium bromide inhalation
Tier 1
ipratropium-albuterol
Tier 1
levalbuterol hcl inhalation
Tier 1
LUFYLLIN
Tier 3
metaproterenol sulfate oral
Tier 3
montelukast sodium oral
Tier 1
QL
PERFOROMIST
Tier 3
PA; ST; N1; QL
PROAIR HFA
Tier 2
QL
PROAIR RESPICLICK
Tier 2
QL
PROVENTIL HFA
Tier 3
ST; N1; QL
PULMICORT
Tier 3
PA; N1
PULMICORT FLEXHALER
Tier 3
ST; N1
QVAR
Tier 2
SEREVENT DISKUS
Tier 2
QL
SINGULAIR
Tier 3
N1; QL
SPIRIVA HANDIHALER
Tier 2
QL
SPIRIVA RESPIMAT
Tier 2
QL
STRIVERDI RESPIMAT
Tier 3
PA; ST; QL
SYMBICORT
Tier 2
QL
terbutaline sulfate oral
Tier 1
THEO-24
Tier 3
THEOCHRON
Tier 1
theophylline er
Tier 1
theophylline oral solution
Tier 1
TUDORZA PRESSAIR
Tier 3
PA; ST; N1; QL
VENTOLIN HFA
Tier 2
QL
VOSPIRE ER
Tier 3
XOLAIR
Tier 2
XOPENEX
Tier 3
XOPENEX CONCENTRATE
Tier 3
XOPENEX HFA
Tier 3
zafirlukast
Tier 1
ZYFLO
Tier 3
ZYFLO CR
Tier 3
PA
ST; N1; QL
(Updated 07/01/15)
16
Drug Name
Drug Status
Drug Details
*ANTICOAGULANTS*
acd formula a
Tier 3
acd formula b
Tier 3
acd-a
Tier 3
ACD-A NOCLOT-50
Tier 3
anticoagulant cit dext soln a
Tier 3
ANTICOAGULANT COMPOUND
Tier 3
ARIXTRA
Tier 3
COUMADIN ORAL
Tier 3
ELIQUIS
Tier 2
QL
enoxaparin sodium
Tier 1
PA; QL
fondaparinux sodium
Tier 3
PA; QL
FRAGMIN
Tier 3
PA; QL
IPRIVASK
Tier 3
PA
JANTOVEN
Tier 1
LOVENOX
Tier 3
PA; QL
PRADAXA
Tier 3
ST; N1; QL
SAVAYSA
Tier 3
ST; QL
warfarin sodium oral
Tier 1
LGC
XARELTO ORAL TABLET 10 MG, 15 MG, 20
MG
Tier 2
QL
XARELTO STARTER PACK
Tier 2
QL
PA; QL
*ANTICONVULSANTS*
APTIOM
Tier 3
BANZEL ORAL SUSPENSION
Tier 3
PA
BANZEL ORAL TABLET
Tier 3
PA; QL
carbamazepine er
Tier 1
carbamazepine oral
Tier 1
CARBATROL
Tier 2
CELONTIN
Tier 2
clonazepam oral
Tier 1
DEPAKENE
Tier 3
DEPAKOTE
Tier 3
N1
DEPAKOTE ER
Tier 3
N1
DEPAKOTE SPRINKLES
Tier 3
N1
DIASTAT ACUDIAL
Tier 2
QL
DIASTAT PEDIATRIC
Tier 2
QL
DILANTIN
Tier 2
DILANTIN INFATABS
Tier 2
(Updated 07/01/15)
17
Drug Name
Drug Status
Drug Details
divalproex sodium
Tier 1
divalproex sodium er
Tier 1
EPITOL
Tier 1
ethosuximide oral
Tier 1
felbamate
Tier 1
FELBATOL
Tier 3
FYCOMPA
Tier 3
PA; QL
gabapentin oral capsule
Tier 1
QL
gabapentin oral solution
Tier 1
QL
gabapentin oral tablet
Tier 1
QL
GABITRIL ORAL TABLET 12 MG, 16 MG, 2
MG, 4 MG
Tier 3
QL
KEPPRA ORAL
Tier 3
N1
KEPPRA XR ORAL TABLET EXTENDED
Tier 3
N1; QL
KLONOPIN
Tier 3
LAMICTAL
Tier 3
LAMICTAL ODT ORAL KIT
Tier 3
ST
LAMICTAL ODT ORAL TABLET
DISPERSIBLE 100 MG, 200 MG, 25 MG, 50 MG
Tier 3
ST; QL
LAMICTAL STARTER
Tier 3
LAMICTAL XR ORAL KIT
Tier 3
ST; N1
LAMICTAL XR ORAL TABLET EXTENDED
RELEASE 24 HR* 100 MG, 200 MG, 25 MG, 250
MG, 300 MG, 50 MG
Tier 3
ST; N1; QL
lamotrigine er oral tablet extended release 24 hr*
100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg
Tier 1
ST; QL
lamotrigine oral tablet
Tier 1
lamotrigine oral tablet chewable
Tier 1
lamotrigine oral tablet dispersible 100 mg, 200 mg,
25 mg, 50 mg
Tier 3
ST; QL
levetiracetam er oral tablet extended release 24 hr*
500 mg, 750 mg
Tier 1
QL
levetiracetam oral
Tier 1
LYRICA ORAL CAPSULE 100 MG, 150 MG,
200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75
MG
Tier 3
PA; ST; N1; QL
LYRICA ORAL SOLUTION
Tier 3
PA; ST; N1; QL
MYSOLINE
Tier 3
NEURONTIN ORAL CAPSULE
Tier 3
NEURONTIN ORAL SOLUTION
Tier 3
LGC
QL
(Updated 07/01/15)
18
Drug Name
Drug Status
Drug Details
NEURONTIN ORAL TABLET
Tier 3
QL
ONFI ORAL SUSPENSION
Tier 3
PA
ONFI ORAL TABLET 10 MG, 20 MG
Tier 3
PA; QL
oxcarbazepine
Tier 1
OXTELLAR XR ORAL TABLET EXTENDED
Tier 3
PEGANONE
Tier 3
PHENYTEK
Tier 2
PHENYTOIN INFATABS
Tier 1
phenytoin oral
Tier 1
phenytoin sodium extended
Tier 1
POTIGA ORAL TABLET 200 MG, 300 MG, 400
MG
Tier 3
PA; QL
POTIGA ORAL TABLET 50 MG
Tier 3
PA
primidone oral
Tier 1
QUDEXY XR
Tier 3
ST; QL
SABRIL ORAL PACKET
Tier 3
QL
SABRIL ORAL TABLET
Tier 3
PA; QL
STAVZOR
Tier 3
TEGRETOL ORAL SUSPENSION
Tier 2
TEGRETOL ORAL TABLET
Tier 2
TEGRETOL-XR
Tier 3
tiagabine hcl oral tablet 2 mg, 4 mg
Tier 1
QL
TOPAMAX
Tier 3
N1
TOPAMAX SPRINKLE
Tier 3
N1; QL
TOPIRAGEN
Tier 1
topiramate oral capsule sprinkle
Tier 1
topiramate oral tablet
Tier 1
TRILEPTAL
Tier 3
TROKENDI XR ORAL CAPSULE EXTENDED
RELEASE 24 HOUR 100 MG, 200 MG, 25 MG,
50 MG
Tier 3
valproic acid oral
Tier 1
VIMPAT ORAL SOLUTION
Tier 3
QL
VIMPAT ORAL TABLET 100 MG, 150 MG, 200
MG, 50 MG
Tier 3
QL
ZARONTIN
Tier 3
ZONEGRAN
Tier 3
zonisamide oral
Tier 1
ST; QL
QL
ST; N1; QL
(Updated 07/01/15)
19
Drug Name
Drug Status
Drug Details
*ANTIDEPRESSANTS*
amitriptyline hcl oral tablet 10 mg, 100 mg, 25 mg,
50 mg, 75 mg
Tier 1
amitriptyline hcl oral tablet 150 mg
Tier 1
ANAFRANIL
Tier 3
APLENZIN
Tier 3
ST; QL
BRINTELLIX
Tier 3
PA; ST; N1; QL
BUDEPRION SR
Tier 1
QL
BUDEPRION XL
Tier 1
QL
bupropion hcl er (sr)
Tier 1
QL
bupropion hcl er (xl)
Tier 1
QL
bupropion hcl oral
Tier 1
QL
CELEXA
Tier 3
N1; QL
citalopram hydrobromide oral solution
Tier 1
citalopram hydrobromide oral tablet
Tier 1
clomipramine hcl oral
Tier 1
CYMBALTA ORAL CAPSULE DELAYED
RELEASE PARTICLES 20 MG, 30 MG, 60 MG
Tier 3
desipramine hcl oral
Tier 1
desvenlafaxine er
Tier 3
doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25
mg, 50 mg
Tier 1
doxepin hcl oral concentrate
Tier 1
duloxetine hcl oral capsule delayed release particles
20 mg, 30 mg, 60 mg
Tier 3
PA; N1; QL
EFFEXOR XR ORAL CAPSULE EXTENDED
RELEASE 24 HOUR 150 MG, 37.5 MG, 75 MG
Tier 3
QL
EMSAM
Tier 3
QL
escitalopram oxalate oral solution
Tier 1
QL
escitalopram oxalate oral tablet
Tier 1
QL
FETZIMA
Tier 3
PA; ST; N1; QL
FETZIMA TITRATION
Tier 3
PA; ST; N1; QL
fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg
Tier 1
LGC; QL
fluoxetine hcl oral capsule delayed release
Tier 1
QL
fluoxetine hcl oral solution
Tier 1
QL
fluoxetine hcl oral tablet 10 mg
Tier 1
LGC; QL
Tier 1
QL
Tier 3
ST; N1; QL
fluvoxamine maleate er
Tier 1
QL
LGC
LGC; QL
PA; ST; N1; QL
PA; ST; N1; QL
(Updated 07/01/15)
20
Drug Name
Drug Status
Drug Details
fluvoxamine maleate oral tablet 100 mg, 25 mg, 50
mg
Tier 1
QL
FORFIVO XL
Tier 3
N1; QL
imipramine hcl oral
Tier 1
imipramine pamoate
Tier 1
KHEDEZLA
Tier 3
PA; ST; N1; QL
LEXAPRO ORAL SOLUTION
Tier 3
QL
LEXAPRO ORAL TABLET
Tier 3
QL
LUVOX CR
Tier 3
QL
MARPLAN
Tier 3
mirtazapine oral tablet 15 mg, 30 mg, 45 mg
Tier 1
QL
mirtazapine oral tablet dispersible
Tier 1
QL
NARDIL
Tier 3
nefazodone hcl oral tablet 250 mg
Tier 3
nefazodone hcl oral tablet 50 mg
Tier 3
NORPRAMIN
Tier 3
nortriptyline hcl oral capsule 10 mg, 25 mg
Tier 1
nortriptyline hcl oral capsule 50 mg, 75 mg
Tier 1
PAMELOR
Tier 3
PARNATE
Tier 3
paroxetine hcl er
Tier 1
QL
paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40
mg
Tier 1
LGC; QL
PAXIL CR
Tier 3
ST; N1; QL
PAXIL ORAL SUSPENSION
Tier 3
QL
PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG,
40 MG
Tier 3
QL
PEXEVA ORAL TABLET 10 MG, 20 MG, 30
MG, 40 MG
Tier 3
ST; QL
phenelzine sulfate oral
Tier 1
PRISTIQ ORAL TABLET EXTENDED
Tier 3
PA; ST; N1; QL
PRISTIQ ORAL TABLET EXTENDED
RELEASE 24 HR* 25 MG
Tier 3
PA; ST; QL
protriptyline hcl
Tier 1
PROZAC ORAL CAPSULE 10 MG, 20 MG, 40
MG
Tier 3
QL
PROZAC WEEKLY
Tier 3
QL
REMERON
Tier 3
ST; N1; QL
REMERON SOLTAB
Tier 3
ST; N1; QL
ST; N1
LGC
(Updated 07/01/15)
21
Drug Name
Drug Status
Drug Details
SENTRAVIL PM-25
Tier 3
sertraline hcl oral concentrate
Tier 1
QL
sertraline hcl oral tablet 100 mg, 25 mg, 50 mg
Tier 1
LGC; QL
SURMONTIL
Tier 3
TOFRANIL
Tier 3
TOFRANIL-PM
Tier 3
tranylcypromine sulfate
Tier 1
trazodone hcl oral
Tier 1
venlafaxine hcl er oral capsule extended release 24
hour 150 mg, 37.5 mg, 75 mg
Tier 1
QL
venlafaxine hcl er oral tablet extended release 24 hr*
150 mg, 37.5 mg, 75 mg
Tier 3
QL
venlafaxine hcl er oral tablet extended release 24 hr*
225 mg
Tier 3
ST; N1; QL
venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg,
50 mg, 75 mg
Tier 1
QL
VIIBRYD
Tier 3
PA; ST; N1; QL
VIVACTIL
Tier 3
WELLBUTRIN
Tier 3
QL
WELLBUTRIN SR
Tier 3
QL
WELLBUTRIN XL
Tier 3
QL
ZOLOFT ORAL CONCENTRATE
Tier 3
QL
ZOLOFT ORAL TABLET 100 MG, 25 MG, 50
MG
Tier 3
QL
*ANTIDIABETICS*
acarbose
Tier 1
ACTOPLUS MET
Tier 3
ST; N1
ACTOPLUS MET XR
Tier 3
ST; N1
ACTOS
Tier 3
ST; N1
AFREZZA
Tier 3
PA; ST
AMARYL
Tier 3
APIDRA
Tier 3
PA; ST; N1
APIDRA SOLOSTAR
Tier 3
PA; ST; N1
AVANDAMET
Tier 3
PA
AVANDARYL
Tier 3
PA
AVANDIA
Tier 3
PA
BD GLUCOSE
Tier 3
BYDUREON SUBCUTANEOUS*
Tier 2
ST; QL
BYDUREON SUBCUTANEOUS*
SUSPENSION RECONSTITUTED
Tier 2
ST; N1; QL
(Updated 07/01/15)
22
Drug Name
Drug Status
Drug Details
BYETTA 10 MCG PEN
Tier 3
ST; N1; QL
BYETTA 5 MCG PEN
Tier 3
ST; N1; QL
chlorpropamide oral tablet 100 mg
Tier 1
LGC
cvs glucose bits
Tier 3
cvs glucose oral
Tier 1
cvs glucose oral tablet chewable
Tier 3
cvs glucose shot oral liquid† 15 gm/59ml
Tier 1
CYCLOSET
Tier 2
DEX4
Tier 3
DEX4 GLUCOSE ORAL
Tier 1
DEX4 GLUCOSE ORAL LIQUID†
Tier 3
DEX4 NATURALS
Tier 3
DEX4 POUCH PACK
Tier 3
DEX4 QUICK DISSOLVE GLUCOSE
Tier 3
DIABETA
Tier 3
drug mart glucose
Tier 3
DUETACT
Tier 3
ST; N1
FARXIGA
Tier 3
PA; ST; N1; QL
glimepiride
Tier 1
LGC
glipizide er oral tablet extended release 24 hr* 10
mg, 5 mg
Tier 1
LGC
glipizide er oral tablet extended release 24 hr* 2.5
mg
Tier 1
glipizide oral
Tier 1
GLIPIZIDE XL
Tier 1
glipizide-metformin hcl
Tier 1
GLUCAGEN HYPOKIT
Tier 3
GLUCAGON EMERGENCY
Tier 3
GLUCO BURST ORAL
Tier 1
GLUCOPHAGE
Tier 3
GLUCOPHAGE XR
Tier 3
glucose oral
Tier 1
glucose oral tablet chewable
Tier 3
GLUCOTROL
Tier 3
GLUCOTROL XL
Tier 3
GLUCOVANCE
Tier 3
GLUMETZA
Tier 3
GLUTOSE 15
Tier 1
GLUTOSE 45
Tier 1
LGC
(Updated 07/01/15)
23
Drug Name
Drug Status
Drug Details
glyburide micronized oral tablet 1.5 mg
Tier 1
glyburide micronized oral tablet 3 mg, 6 mg
Tier 1
glyburide oral tablet 1.25 mg
Tier 1
glyburide oral tablet 2.5 mg, 5 mg
Tier 1
glyburide-metformin
Tier 1
GLYNASE
Tier 3
GLYSET
Tier 3
GLYXAMBI
Tier 3
gnp glucose
Tier 3
gnp quick dissolve glucose
Tier 3
hm glucose
Tier 3
HUMALOG KWIKPEN
Tier 2
HUMALOG MIX 50/50
Tier 2
HUMALOG MIX 50/50 KWIKPEN
Tier 2
HUMALOG MIX 75/25
Tier 2
HUMALOG MIX 75/25 KWIKPEN
Tier 2
HUMULIN 70/30 KWIKPEN
Tier 2
HUMULIN 70/30 PEN
Tier 2
HUMULIN N KWIKPEN
Tier 2
HUMULIN N PEN
Tier 2
HUMULIN R U-500 (CONCENTRATED)
Tier 2
hy-vee glucose
Tier 3
INSTA-GLUCOSE ORAL 40 %
Tier 1
INVOKAMET ORAL TABLET 150-1000 MG,
150-500 MG, 50-1000 MG, 50-500 MG
Tier 2
ST; QL
INVOKANA
Tier 2
ST; N1; QL
JANUMET
Tier 2
ST; N1; QL
JANUMET XR ORAL TABLET EXTENDED
RELEASE 24 HR* 100-1000 MG, 50-1000 MG,
50-500 MG
Tier 2
ST; N1; QL
JANUVIA
Tier 2
ST; N1; QL
JARDIANCE
Tier 3
PA; ST; QL
JENTADUETO
Tier 3
PA; ST; N1; QL
KAZANO
Tier 3
PA; ST; N1; QL
KOMBIGLYZE XR ORAL TABLET
EXTENDED RELEASE 24 HR* 2.5-1000 MG,
5-1000 MG, 5-500 MG
Tier 2
ST; N1; QL
KORLYM
Tier 3
PA; QL
kroger glucose
Tier 3
LGC
LGC
ST; QL
LANTUS
Tier 3
PA; ST; N1
(Updated 07/01/15)
24
Drug Name
Drug Status
Drug Details
LANTUS SOLOSTAR
Tier 3
PA; ST; N1
leader glucose
Tier 3
leader quick dissolve glucose
Tier 3
LEVEMIR
Tier 2
LEVEMIR FLEXPEN
Tier 2
longs glucose
Tier 3
meijer glucose
Tier 3
metformin hcl er (osm)
Tier 1
metformin hcl er oral tablet extended release 24 hr*
500 mg
Tier 1
metformin hcl er oral tablet extended release 24 hr*
750 mg
Tier 1
metformin hcl oral
Tier 1
ms quick dissolve glucose
Tier 3
nateglinide
Tier 1
NESINA
Tier 3
PA; ST; N1; QL
NOVOLIN 70/30
Tier 3
PA; ST; N1
NOVOLIN 70/30 RELION
Tier 3
PA; ST; N1
NOVOLIN N
Tier 3
PA; ST; N1
NOVOLIN N RELION
Tier 3
PA; ST; N1
NOVOLIN R
Tier 3
PA; ST; N1
NOVOLIN R RELION
Tier 3
PA; ST; N1
NOVOLOG
Tier 3
PA; ST; N1
NOVOLOG FLEXPEN
Tier 3
PA; ST; N1
NOVOLOG MIX 70/30
Tier 3
PA; ST; N1
NOVOLOG MIX 70/30 FLEXPEN
Tier 3
PA; ST; N1
ONGLYZA
Tier 2
ST; N1; QL
OSENI
Tier 3
PA; ST; N1; QL
pioglitazone hcl
Tier 1
pioglitazone hcl-glimepiride
Tier 1
pioglitazone hcl-metformin hcl
Tier 1
PRANDIMET
Tier 3
PRANDIN
Tier 3
PRECOSE
Tier 3
preferred plus glucose
Tier 3
PROGLYCEM
Tier 2
px glucose
Tier 3
ra glucose oral
Tier 1
ra glucose oral tablet chewable
Tier 3
LGC
LGC
ST; N1
(Updated 07/01/15)
25
Drug Name
Drug Status
Drug Details
RELION GLUCOSE DRINK
Tier 1
RELION GLUCOSE ORAL
Tier 1
RELION GLUCOSE ORAL TABLET
CHEWABLE
Tier 3
repaglinide
Tier 1
RIOMET
Tier 3
sm glucose
Tier 3
SMART SENSE GLUCOSE
Tier 3
STARLIX
Tier 3
SYMLINPEN 120
Tier 2
PA
SYMLINPEN 60
Tier 2
PA
TANZEUM
Tier 3
PA; ST; N1; QL
tgt glucose oral tablet chewable 4-6 gm-mg
Tier 3
tolazamide oral tablet 250 mg
Tier 1
TOUJEO SOLOSTAR
Tier 3
PA; ST
TRADJENTA
Tier 3
PA; ST; N1; QL
TRULICITY
Tier 3
PA; ST; QL
ultilet glucose
Tier 3
up & up glucose
Tier 3
value plus glucose oral
Tier 1
value plus glucose oral tablet chewable
Tier 3
VICTOZA
Tier 3
walgreens glucose
Tier 3
XIGDUO XR
Tier 3
PA; ST; N1; QL
ST; QL
*ANTIDIARRHEALS*
diphenatol
Tier 1
diphenoxylate-atropine oral tablet
Tier 1
FULYZAQ
Tier 3
lofene
Tier 1
LOMOTIL
Tier 3
LONOX
Tier 1
MOTOFEN
Tier 3
opium
Tier 1
PA; QL
*ANTIDOTES*
CHEMET
Tier 2
deferoxamine mesylate
Tier 1
DEPADE
Tier 1
DESFERAL
Tier 3
EVZIO
Tier 2
PA
(Updated 07/01/15)
26
Drug Name
Drug Status
EXJADE
Tier 3
FERRIPROX
Tier 3
JADENU
Tier 3
naltrexone hcl oral
Tier 1
RADIOGARDASE
Tier 2
REVIA
Tier 3
VIVITROL
Tier 3
Drug Details
PA
*ANTIEMETICS*
AKYNZEO
Tier 3
PA; QL
ANZEMET ORAL
Tier 3
QL
CESAMET
Tier 3
QL
DICLEGIS
Tier 3
N1; QL
dronabinol
Tier 1
PA
EMEND ORAL CAPSULE 125 MG, 40 MG, 80
& 125 MG, 80 MG
Tier 2
#; QL
granisetron hcl oral
Tier 1
QL
GRANISOL
Tier 3
QL
MARINOL
Tier 3
PA
ondansetron
Tier 1
QL
ondansetron hcl oral solution
Tier 1
QL
ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg
Tier 1
QL
SANCUSO
Tier 3
QL
TIGAN ORAL
Tier 3
trimethobenzamide hcl oral
Tier 1
ZOFRAN ODT
Tier 3
QL
ZOFRAN ORAL SOLUTION
Tier 3
QL
ZOFRAN ORAL TABLET
Tier 3
QL
ZUPLENZ
Tier 3
QL
*ANTIFUNGALS*
bio-statin oral capsule
Tier 3
bio-statin oral powder
Tier 1
CRESEMBA ORAL
Tier 3
DIFLUCAN ORAL SUSPENSION
RECONSTITUTED
Tier 3
PA
DIFLUCAN ORAL TABLET 100 MG, 200 MG,
50 MG
Tier 3
PA
DIFLUCAN ORAL TABLET 150 MG
Tier 3
QL
fluconazole oral suspension reconstituted
Tier 1
PA
fluconazole oral tablet 100 mg, 200 mg, 50 mg
Tier 1
PA
(Updated 07/01/15)
27
Drug Name
Drug Status
Drug Details
fluconazole oral tablet 150 mg
Tier 1
QL
flucytosine oral
Tier 1
GRIFULVIN V
Tier 3
griseofulvin microsize oral
Tier 1
griseofulvin ultramicrosize
Tier 1
GRIS-PEG
Tier 3
itraconazole oral
Tier 1
ketoconazole oral
Tier 1
LAMISIL
Tier 3
NOXAFIL
Tier 3
nystatin oral
Tier 1
ONMEL
Tier 3
PA
SPORANOX
Tier 3
PA
SPORANOX PULSEPAK
Tier 3
PA
terbinafine hcl oral
Tier 1
PA
VFEND
Tier 3
voriconazole oral
Tier 1
PA
PA
*ANTIHISTAMINES*
ARBINOXA
Tier 1
carbinoxamine maleate oral
Tier 1
cetirizine hcl allergy child
Tier 3
cetirizine hcl oral syrup 1 mg/ml
Tier 3
cetirizine hcl oral syrup 5 mg/5ml
Tier 3
cetirizine hcl oral tablet 10 mg
Tier 3
CLARINEX ORAL SYRUP
Tier 3
PA; QL
CLARINEX ORAL TABLET
Tier 3
PA; QL
CLARINEX REDITABS
Tier 3
PA; QL
clemastine fumarate oral tablet 2.68 mg
Tier 1
cyproheptadine hcl oral
Tier 1
desloratadine
Tier 1
DOXYTEX
Tier 3
ED CHLORPED ORAL SUSPENSION
Tier 3
ED-CHLOR-TAN
Tier 3
fexofenadine hcl oral tablet 30 mg
Tier 3
KARBINAL ER
Tier 3
kp cetirizine hcl oral tablet 5 mg
Tier 1
LGC
levocetirizine dihydrochloride oral solution
Tier 1
PA; QL
levocetirizine dihydrochloride oral tablet
Tier 1
PA; QL
LGC
PA; QL
(Updated 07/01/15)
28
Drug Name
Drug Status
Drug Details
loratadine oral tablet
Tier 1
LGC
PALGIC ORAL SOLUTION
Tier 3
PHENADOZ
Tier 1
PA
promethazine hcl oral
Tier 1
PA
promethazine hcl suppository 12.5 mg, 25 mg
Tier 1
PA
PROMETHEGAN SUPPOSITORY 12.5 MG, 25
MG
Tier 1
PA
PROMETHEGAN SUPPOSITORY 50 MG
Tier 3
PA
RESPA-BR
Tier 3
WAL-ITIN ORAL SYRUP
Tier 1
LGC
XYZAL ORAL SOLUTION
Tier 3
PA; QL
XYZAL ORAL TABLET
Tier 3
PA; QL
ADVICOR
Tier 3
QL
ALTOPREV ORAL TABLET EXTENDED
Tier 3
ST; N1; QL
ANTARA
Tier 3
ST; N1
atorvastatin calcium oral
Tier 1
QL
cholestyramine light
Tier 1
cholestyramine oral
Tier 1
COLESTID FLAVORED ORAL PACKET
Tier 3
COLESTID ORAL PACKET
Tier 3
COLESTID ORAL TABLET
Tier 3
colestipol hcl
Tier 1
CRESTOR
Tier 2
fenofibrate micronized
Tier 1
fenofibrate oral tablet
Tier 1
fenofibric acid oral capsule delayed release
Tier 1
FENOGLIDE
Tier 3
ST; N1; #
FIBRICOR
Tier 3
ST; N1
fluvastatin sodium
Tier 1
QL
gemfibrozil oral
Tier 1
LGC
JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5
MG
Tier 3
PA; ST; N1; QL
JUXTAPID ORAL CAPSULE 30 MG, 40 MG, 60
MG
Tier 3
PA; ST; QL
LESCOL
Tier 3
ST; N1; QL
LESCOL XL
Tier 3
ST; N1; QL
LIPITOR
Tier 3
ST; N1; QL
*ANTIHYPERLIPIDEMICS*
QL
(Updated 07/01/15)
29
Drug Name
Drug Status
Drug Details
LIPOFEN
Tier 3
ST; N1; #
LIPTRUZET
Tier 3
ST; N1; QL
LIVALO
Tier 3
ST; N1; QL
LOFIBRA
Tier 3
ST; N1
LOPID
Tier 3
ST; N1
lovastatin
Tier 1
LGC; QL
LOVAZA
Tier 3
N1; QL
MEVACOR
Tier 3
QL
micronized colestipol hcl
Tier 1
niacin er (antihyperlipidemic)
Tier 1
NIACOR
Tier 3
ST; N1
NIASPAN
Tier 3
N1
omega-3-acid ethyl esters
Tier 3
ST; N1; QL
PRAVACHOL ORAL TABLET 20 MG, 40 MG,
80 MG
Tier 3
QL
pravastatin sodium
Tier 1
LGC; QL
PREVALITE
Tier 1
QUESTRAN
Tier 3
QUESTRAN LIGHT ORAL POWDER
Tier 3
SIMCOR ORAL TABLET EXTENDED
RELEASE 24 HR* 1000-20 MG, 1000-40 MG,
500-20 MG, 500-40 MG, 750-20 MG
Tier 3
QL
simvastatin oral
Tier 1
LGC; QL
TRICOR
Tier 3
ST; N1
TRIGLIDE ORAL TABLET 160 MG
Tier 3
ST; N1
TRILIPIX
Tier 3
ST; N1
VASCEPA
Tier 2
ST; QL
VYTORIN
Tier 3
ST; N1; QL
WELCHOL
Tier 2
#
ZETIA
Tier 2
QL
ZOCOR
Tier 3
QL
*ANTIHYPERTENSIVES*
ACCUPRIL
Tier 3
ACCURETIC
Tier 3
ACEON ORAL TABLET 4 MG, 8 MG
Tier 3
ALTACE
Tier 3
amlodipine besy-benazepril hcl
Tier 1
amlodipine besylate-valsartan
Tier 1
QL
amlodipine-valsartan-hctz
Tier 1
QL
(Updated 07/01/15)
30
Drug Name
Drug Status
Drug Details
AMTURNIDE
Tier 3
QL
ATACAND HCT ORAL TABLET 16-12.5 MG
Tier 3
PA; ST; N1; QL
ATACAND HCT ORAL TABLET 32-12.5 MG,
32-25 MG
Tier 3
PA; ST; N1
ATACAND ORAL TABLET 16 MG, 4 MG, 8
MG
Tier 3
PA; ST; N1; QL
ATACAND ORAL TABLET 32 MG
Tier 3
PA; ST; N1
atenolol-chlorthalidone
Tier 1
LGC
AVALIDE ORAL TABLET 150-12.5 MG
Tier 3
PA; ST; N1; QL
AVALIDE ORAL TABLET 300-12.5 MG
Tier 3
PA; ST; N1
AVAPRO ORAL TABLET 150 MG, 75 MG
Tier 3
PA; ST; N1; QL
AVAPRO ORAL TABLET 300 MG
Tier 3
PA; ST; N1
AZOR
Tier 3
PA; ST; N1; QL
benazepril hcl oral
Tier 1
LGC
benazepril-hydrochlorothiazide
Tier 1
LGC
BENICAR HCT ORAL TABLET 20-12.5 MG
Tier 3
PA; ST; N1; QL
BENICAR HCT ORAL TABLET 40-12.5 MG,
40-25 MG
Tier 3
PA; ST; N1
BENICAR ORAL TABLET 20 MG, 5 MG
Tier 3
PA; ST; N1; QL
BENICAR ORAL TABLET 40 MG
Tier 3
PA; ST; N1
bisoprolol-hydrochlorothiazide
Tier 1
LGC
candesartan cilexetil oral tablet 16 mg, 4 mg, 8 mg
Tier 1
QL
candesartan cilexetil oral tablet 32 mg
Tier 1
candesartan cilexetil-hctz oral tablet 16-12.5 mg
Tier 1
candesartan cilexetil-hctz oral tablet 32-12.5 mg,
32-25 mg
Tier 1
captopril oral
Tier 1
CARDURA
Tier 3
CATAPRES
Tier 3
CATAPRES-TTS-1
Tier 3
CATAPRES-TTS-2
Tier 3
CATAPRES-TTS-3
Tier 3
clonidine hcl oral
Tier 1
clonidine hcl transdermal
Tier 1
CLORPRES
Tier 3
CORZIDE
Tier 3
COZAAR ORAL TABLET 25 MG, 50 MG
Tier 3
DEMSER
Tier 3
DIBENZYLINE
Tier 2
QL
LGC
LGC
PA; ST; N1; QL
(Updated 07/01/15)
31
Drug Name
Drug Status
Drug Details
DIOVAN HCT ORAL TABLET 160-12.5 MG,
160-25 MG, 80-12.5 MG
Tier 3
PA; ST; N1; QL
DIOVAN HCT ORAL TABLET 320-12.5 MG,
320-25 MG
Tier 3
PA; ST; N1
DIOVAN ORAL TABLET 160 MG, 40 MG, 80
MG
Tier 3
PA; ST; N1; QL
DIOVAN ORAL TABLET 320 MG
Tier 3
PA; ST; N1
doxazosin mesylate
Tier 1
LGC
DUTOPROL
Tier 2
EDARBI
Tier 3
PA; ST; N1; QL
EDARBYCLOR
Tier 3
PA; ST; N1; QL
enalapril maleate oral
Tier 1
LGC
enalapril-hydrochlorothiazide
Tier 1
LGC
EPANED
Tier 3
PA; ST; N1
eplerenone
Tier 1
eprosartan mesylate
Tier 1
EXFORGE
Tier 2
#; QL
EXFORGE HCT
Tier 2
#; QL
fosinopril sodium
Tier 1
fosinopril sodium-hctz
Tier 1
guanfacine hcl oral
Tier 1
hydralazine hcl oral tablet 10 mg, 100 mg, 50 mg
Tier 1
hydralazine hcl oral tablet 25 mg
Tier 1
LGC
HYZAAR ORAL TABLET 100-12.5 MG, 100-25
MG
Tier 3
PA; ST; N1
HYZAAR ORAL TABLET 50-12.5 MG
Tier 3
PA; ST; N1; QL
INSPRA
Tier 3
irbesartan oral tablet 150 mg, 75 mg
Tier 1
irbesartan oral tablet 300 mg
Tier 1
irbesartan-hydrochlorothiazide oral tablet 150-12.5
mg
Tier 1
irbesartan-hydrochlorothiazide oral tablet 300-12.5
mg
Tier 1
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg
Tier 1
lisinopril oral tablet 30 mg, 40 mg
Tier 1
lisinopril-hydrochlorothiazide
Tier 1
LOPRESSOR HCT
Tier 3
losartan potassium oral tablet 100 mg
Tier 1
LGC
losartan potassium oral tablet 25 mg, 50 mg
Tier 1
LGC; QL
QL
QL
LGC
LGC
(Updated 07/01/15)
32
Drug Name
Drug Status
Drug Details
losartan potassium-hctz oral tablet 100-12.5 mg,
100-25 mg
Tier 1
LGC
losartan potassium-hctz oral tablet 50-12.5 mg
Tier 1
LGC; QL
LOTENSIN
Tier 3
LOTENSIN HCT
Tier 3
LOTREL ORAL CAPSULE 10-20 MG, 2.5-10
MG, 5-10 MG, 5-20 MG
Tier 3
LOTREL ORAL CAPSULE 10-40 MG, 5-40 MG
Tier 3
MAVIK
Tier 3
methyldopa oral
Tier 1
metoprolol-hydrochlorothiazide
Tier 1
MINIPRESS
Tier 3
minoxidil oral
Tier 1
moexipril hcl
Tier 1
moexipril-hydrochlorothiazide
Tier 1
nadolol-bendroflumethiazide
Tier 1
perindopril erbumine
Tier 1
prazosin hcl oral
Tier 1
PRINIVIL
Tier 3
PRINZIDE
Tier 3
quinapril hcl
Tier 1
quinapril-hydrochlorothiazide
Tier 1
ramipril
Tier 1
TARKA
Tier 3
#
TEKAMLO
Tier 3
QL
TEKTURNA
Tier 3
QL
TEKTURNA HCT ORAL TABLET 150-12.5
MG, 150-25 MG
Tier 3
QL
TEKTURNA HCT ORAL TABLET 300-12.5
MG, 300-25 MG
Tier 3
TENEX
Tier 3
TENORETIC 100
Tier 3
TENORETIC 50
Tier 3
terazosin hcl oral
Tier 1
LGC
TEVETEN HCT
Tier 3
PA; ST; N1; #
TEVETEN ORAL TABLET 600 MG
Tier 3
PA; ST; N1
trandolapril
Tier 1
trandolapril-verapamil hcl er
Tier 1
TRIBENZOR
Tier 3
ST; N1
LGC
PA; ST; N1; QL
(Updated 07/01/15)
33
Drug Name
Drug Status
UNIRETIC ORAL TABLET 15-12.5 MG,
7.5-12.5 MG
Tier 3
UNIVASC
Tier 3
valsartan-hydrochlorothiazide oral tablet 160-12.5
mg, 160-25 mg, 80-12.5 mg
Tier 1
valsartan-hydrochlorothiazide oral tablet 320-12.5
mg, 320-25 mg
Tier 1
VASERETIC
Tier 3
VASOTEC
Tier 3
VECAMYL
Tier 3
ZESTORETIC
Tier 3
ZESTRIL
Tier 3
ZIAC
Tier 3
Drug Details
QL
PA; ST; N1; QL
*ANTI-INFECTIVE AGENTS - MISC.*
ALINIA
Tier 3
BACTRIM
Tier 3
BACTRIM DS
Tier 3
CAYSTON
Tier 3
CLEOCIN ORAL CAPSULE 150 MG, 300 MG
Tier 3
CLEOCIN ORAL SOLUTION
RECONSTITUTED
Tier 3
clindamycin hcl oral
Tier 1
clindamycin palmitate hcl
Tier 1
colistimethate sodium injection
Tier 1
COLY-MYCIN M
Tier 3
E.S.P.
Tier 1
erythromycin-sulfisoxazole
Tier 1
FIRST-VANCOMYCIN 25
Tier 3
FIRST-VANCOMYCIN 50
Tier 3
FLAGYL ER
Tier 3
FLAGYL ORAL TABLET
Tier 3
KETEK
Tier 3
metronidazole oral tablet
Tier 1
NEBUPENT
Tier 2
PRIMSOL
Tier 3
SEPTRA DS
Tier 3
SIVEXTRO ORAL
Tier 3
smz-tmp ds
Tier 1
sulfamethoxazole-tmp ds
Tier 1
PA; QL
LGC
(Updated 07/01/15)
34
Drug Name
Drug Status
Drug Details
sulfamethoxazole-trimethoprim oral suspension
Tier 1
sulfamethoxazole-trimethoprim oral tablet
Tier 1
SULFATRIM PEDIATRIC
Tier 1
TINDAMAX
Tier 3
tinidazole oral
Tier 1
trimethoprim oral
Tier 1
VANCOCIN HCL
Tier 3
vancomycin hcl oral
Tier 1
XIFAXAN ORAL TABLET 200 MG, 550 MG
Tier 3
ZYVOX ORAL SUSPENSION
RECONSTITUTED
Tier 2
ZYVOX ORAL TABLET
Tier 2
#
ARALEN
Tier 3
QL
atovaquone-proguanil hcl oral tablet 250-100 mg
Tier 1
PA
chloroquine phosphate oral
Tier 1
QL
COARTEM
Tier 3
PA
DARAPRIM
Tier 3
QL
hydroxychloroquine sulfate oral
Tier 1
QL
MALARONE
Tier 3
PA
mefloquine hcl
Tier 1
PA
PLAQUENIL
Tier 3
QL
QUALAQUIN
Tier 3
QL
quinine sulfate oral
Tier 1
QL
LGC
PA; QL
*ANTIMALARIALS*
*ANTIMYASTHENIC/CHOLINERGIC
AGENTS*
MESTINON
Tier 2
pyridostigmine bromide oral
Tier 1
*ANTIMYCOBACTERIAL AGENTS*
ethambutol hcl oral
Tier 1
isoniazid oral tablet
Tier 1
MYAMBUTOL
Tier 2
PASER
Tier 3
PRIFTIN
Tier 3
pyrazinamide oral
Tier 1
RIFADIN ORAL
Tier 3
RIFAMATE
Tier 3
rifampin oral
Tier 1
RIFATER
Tier 3
(Updated 07/01/15)
35
Drug Name
Drug Status
SIRTURO
Tier 3
TRECATOR
Tier 3
Drug Details
PA; ST; N1; QL
*ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES*
ACTIMMUNE
Tier 3
PA
AFINITOR
Tier 3
PA; SF; QL
AFINITOR DISPERZ
Tier 3
PA; SF; QL
ALFERON N
Tier 3
ALKERAN ORAL
Tier 2
anastrozole oral
Tier 1
PA
ARIMIDEX
Tier 3
PA; ST; N1
AROMASIN
Tier 3
PA
bicalutamide
Tier 1
PA
BOSULIF
Tier 3
PA; ST
CAPRELSA
Tier 3
PA; QL
CASODEX
Tier 3
PA
COMETRIQ (100 MG DAILY DOSE)
Tier 3
PA; QL
Tier 3
PA; QL
Tier 3
PA; QL
ELIGARD
Tier 3
EMCYT
Tier 2
ERIVEDGE
Tier 3
PA; QL
exemestane
Tier 1
PA
FARESTON
Tier 3
FARYDAK
Tier 3
FASLODEX
Tier 3
FEMARA
Tier 3
PA; ST; N1
FIRMAGON
Tier 3
PA
flutamide
Tier 1
GILOTRIF
Tier 3
PA; QL
GLEEVEC
Tier 2
PA; QL
GLEOSTINE
Tier 3
HEXALEN
Tier 2
HYCAMTIN ORAL
Tier 3
hydroxyurea oral
Tier 1
IBRANCE
Tier 3
PA; QL
ICLUSIG
Tier 3
PA; ST; QL
IMBRUVICA
Tier 3
PA; QL
PA; QL
QL
INLYTA
Tier 3
PA; SF; QL
(Updated 07/01/15)
36
Drug Name
Drug Status
INTRON-A
Tier 2
JAKAFI
Tier 3
PA; SF; QL
LENVIMA 10 MG DAILY DOSE
Tier 3
PA; QL
Tier 3
PA; QL
Tier 3
PA; QL
Tier 3
PA; QL
letrozole oral
Tier 1
PA
leucovorin calcium oral tablet 25 mg, 5 mg
Tier 1
LEUKERAN
Tier 2
leuprolide acetate injection
Tier 1
LUPRON DEPOT
Tier 2
LYNPARZA
Tier 3
LYSODREN
Tier 3
MATULANE
Tier 2
MEGACE ORAL
Tier 3
megestrol acetate oral
Tier 1
MEKINIST
Tier 3
mercaptopurine oral
Tier 1
MESNEX ORAL
Tier 3
methotrexate oral
Tier 1
MYLERAN
Tier 2
NEXAVAR
Tier 3
NILANDRON
Tier 2
POMALYST
Tier 3
PURINETHOL
Tier 3
SOLTAMOX
Tier 3
SPRYCEL
Tier 3
PA; ST; SF; QL
STIVARGA
Tier 3
PA
SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 50
MG
Tier 2
PA; SF; QL
TABLOID
Tier 2
TAFINLAR
Tier 3
tamoxifen citrate oral
Drug Details
PA; QL
PA; SF; QL
PA; SF; QL
PA; QL
PA; SF; QL
CE
TARCEVA
Tier 2
PA; SF; QL
TARGRETIN ORAL
Tier 2
#
TASIGNA
Tier 2
PA; ST; QL
TEMODAR ORAL
Tier 2
PA; QL
temozolomide
Tier 1
PA; QL
TRELSTAR MIXJECT
Tier 3
#
(Updated 07/01/15)
37
Drug Name
Drug Status
Drug Details
tretinoin oral
Tier 1
TREXALL
Tier 3
TYKERB
Tier 3
VANTAS
Tier 3
VOTRIENT
Tier 3
PA; SF; QL
XALKORI
Tier 3
PA; QL
XELODA
Tier 3
PA; ST; N1; QL
XTANDI
Tier 3
PA; QL
ZELBORAF
Tier 3
PA; SF; QL
ZOLADEX
Tier 3
ZOLINZA
Tier 3
PA; QL
ZYTIGA
Tier 2
PA; QL
QL
PA; QL
*ANTIPARKINSON AGENTS*
amantadine hcl oral capsule
Tier 1
amantadine hcl oral syrup
Tier 1
AZILECT
Tier 2
QL
benztropine mesylate oral
Tier 1
LGC
bromocriptine mesylate oral
Tier 1
carbidopa oral
Tier 3
carbidopa-levodopa
Tier 1
carbidopa-levodopa er oral tablet extendedrelease*
50-200 mg
Tier 1
carbidopa-levodopa-entacapone oral tablet
12.5-50-200 mg, 18.75-75-200 mg
Tier 3
COMTAN
Tier 3
DUOPA
Tier 3
ELDEPRYL
Tier 3
entacapone
Tier 1
MIRAPEX
Tier 3
MIRAPEX ER
Tier 3
N1; QL
NEUPRO
Tier 3
QL
PARLODEL
Tier 3
pramipexole dihydrochloride
Tier 1
pramipexole dihydrochloride er
Tier 1
REQUIP
Tier 3
REQUIP XL ORAL TABLET EXTENDED
RELEASE 24 HR* 12 MG, 2 MG, 4 MG, 6 MG, 8
MG
Tier 3
ropinirole hcl
Tier 1
PA; ST; QL
N1; QL
(Updated 07/01/15)
38
Drug Name
Drug Status
Drug Details
ropinirole hcl er oral tablet extended release 24 hr*
12 mg, 2 mg, 4 mg, 6 mg, 8 mg
Tier 3
RYTARY
Tier 3
selegiline hcl oral
Tier 1
SINEMET
Tier 3
SINEMET CR
Tier 3
STALEVO 100
Tier 3
STALEVO 125
Tier 3
STALEVO 150
Tier 3
STALEVO 200
Tier 3
STALEVO 50
Tier 3
STALEVO 75
Tier 3
TASMAR
Tier 3
tolcapone
Tier 1
trihexyphenidyl hcl oral elixir
Tier 1
trihexyphenidyl hcl oral tablet 2 mg
Tier 1
trihexyphenidyl hcl oral tablet 5 mg
Tier 1
ZELAPAR
Tier 3
QL
ABILIFY DISCMELT
Tier 3
#; QL
ABILIFY MAINTENA
Tier 3
QL
ABILIFY ORAL SOLUTION
Tier 3
ST; N1; QL
ABILIFY ORAL TABLET
Tier 3
ST; N1; #; QL
aripiprazole
Tier 1
QL
chlorpromazine hcl oral
Tier 1
clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg
Tier 1
QL
clozapine oral tablet dispersible 150 mg, 200 mg
Tier 1
QL
CLOZARIL ORAL TABLET 100 MG, 25 MG
Tier 3
QL
COMPAZINE
Tier 1
COMPRO
Tier 1
EQUETRO
Tier 3
FANAPT
Tier 3
ST; N1; QL
FANAPT TITRATION PACK
Tier 3
ST; N1; QL
FAZACLO ORAL TABLET DISPERSIBLE 100
MG, 12.5 MG, 150 MG, 200 MG, 25 MG
Tier 3
#; QL
fluphenazine hcl oral tablet
Tier 1
GEODON ORAL
Tier 3
haloperidol lactate oral
Tier 1
haloperidol oral
Tier 1
QL
LGC
*ANTIPSYCHOTICS/ANTIMANIC AGENTS*
ST; N1; QL
(Updated 07/01/15)
39
Drug Name
Drug Status
Drug Details
INVEGA ORAL TABLET EXTENDED
RELEASE 24 HR* 1.5 MG, 3 MG, 6 MG, 9 MG
Tier 3
ST; N1; QL
LATUDA ORAL TABLET 120 MG, 20 MG, 40
MG, 60 MG, 80 MG
Tier 2
ST; N1; QL
lithium carbonate er
Tier 1
lithium carbonate oral
Tier 1
LITHOBID
Tier 3
loxapine succinate oral
Tier 1
LOXITANE ORAL CAPSULE 5 MG
Tier 3
olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg,
5 mg, 7.5 mg
Tier 1
QL
olanzapine oral tablet dispersible
Tier 1
QL
perphenazine oral
Tier 1
prochlorperazine
Tier 1
prochlorperazine maleate oral
Tier 1
quetiapine fumarate oral tablet 100 mg, 200 mg, 25
mg, 300 mg, 400 mg, 50 mg
Tier 1
QL
RISPERDAL M-TAB ORAL TABLET
DISPERSIBLE 0.5 MG, 1 MG, 2 MG, 3 MG, 4
MG
Tier 3
ST; N1; QL
RISPERDAL ORAL SOLUTION
Tier 3
ST; N1
RISPERDAL ORAL TABLET 0.25 MG, 0.5 MG,
1 MG, 2 MG, 3 MG, 4 MG
Tier 3
ST; N1; QL
RISPERIDONE M-TAB ORAL TABLET
DISPERSIBLE 0.5 MG, 1 MG, 2 MG, 3 MG, 4
MG
Tier 1
ST; QL
risperidone oral solution
Tier 1
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg,
3 mg, 4 mg
Tier 1
QL
risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1
mg, 2 mg, 3 mg, 4 mg
Tier 1
ST; N1; QL
SAPHRIS SUBLINGUAL TABLET
SUBLINGUAL 10 MG, 5 MG
Tier 3
ST; N1; QL
SAPHRIS SUBLINGUAL TABLET
SUBLINGUAL 2.5 MG
Tier 3
ST; QL
SEROQUEL ORAL TABLET 100 MG, 200 MG,
25 MG, 300 MG, 400 MG, 50 MG
Tier 3
ST; N1; QL
SEROQUEL XR ORAL TABLET EXTENDED
RELEASE 24 HR* 150 MG, 200 MG, 300 MG,
400 MG, 50 MG
Tier 3
PA; ST; N1; QL
thioridazine hcl oral
Tier 1
thiothixene oral
Tier 1
(Updated 07/01/15)
40
Drug Name
Drug Status
Drug Details
trifluoperazine hcl oral
Tier 1
VERSACLOZ
Tier 3
ST; N1
ziprasidone hcl
Tier 1
QL
ZYPREXA ORAL TABLET 10 MG, 15 MG, 2.5
MG, 20 MG, 5 MG, 7.5 MG
Tier 3
ST; N1; QL
ZYPREXA ZYDIS
Tier 3
ST; N1; QL
*ANTISEPTICS & DISINFECTANTS*
BUCALSEP EXTERNAL SOLUTION
Tier 3
DURAPREP
Tier 3
FORMADON
Tier 1
formaldehyde external solution 10 %
Tier 1
FORMA-RAY
Tier 3
KERR TRIPLE DYE SWABS
Tier 3
LAZERFORMALYDE
Tier 1
*ANTIVIRALS*
abacavir sulfate
Tier 1
abacavir-lamivudine-zidovudine
Tier 1
acyclovir oral capsule
Tier 1
acyclovir oral suspension
Tier 1
acyclovir oral tablet 400 mg
Tier 1
acyclovir oral tablet 800 mg
Tier 1
adefovir dipivoxil
Tier 1
APTIVUS
Tier 2
ATRIPLA
Tier 3
#
BARACLUDE
Tier 3
#
cidofovir intravenous*
Tier 1
COMBIVIR
Tier 3
COMPLERA
Tier 3
COPEGUS
Tier 3
CRIXIVAN
Tier 3
CYTOVENE
Tier 3
didanosine
Tier 1
EDURANT
Tier 3
EMTRIVA
Tier 3
entecavir
Tier 1
EPIVIR HBV ORAL SOLUTION
Tier 3
EPIVIR ORAL SOLUTION
Tier 2
EPIVIR ORAL TABLET
Tier 3
LGC
LGC
ST; N1
EPZICOM
Tier 3
(Updated 07/01/15)
41
Drug Name
Drug Status
Drug Details
EVOTAZ
Tier 3
famciclovir oral tablet 125 mg, 250 mg, 500 mg
Tier 1
QL
FAMVIR ORAL TABLET 125 MG, 250 MG, 500
MG
Tier 3
QL
FLUMADINE
Tier 3
FOSCAVIR
Tier 3
FUZEON SUBCUTANEOUS* KIT
Tier 3
FUZEON SUBCUTANEOUS* SOLUTION
RECONSTITUTED
Tier 3
ganciclovir sodium
Tier 1
HARVONI
Tier 3
HEPSERA
Tier 3
INCIVEK
Tier 2
INTELENCE
Tier 3
INVIRASE
Tier 3
ISENTRESS
Tier 3
KALETRA
Tier 2
lamivudine
Tier 1
lamivudine-zidovudine
Tier 1
LEXIVA
Tier 2
MODERIBA 1200 DOSE PACK
Tier 3
Tier 3
MODERIBA ORAL
Tier 3
MODERIBA ORAL TABLET
Tier 2
nevirapine
Tier 1
nevirapine er
Tier 1
NORVIR
Tier 2
OLYSIO
Tier 3
PA; QL
PEGASYS
Tier 2
PA
PEGASYS PROCLICK
Tier 2
PA
PEG-INTRON
Tier 2
PA
PEG-INTRON REDIPEN
Tier 2
PA
PEG-INTRON REDIPEN PAK 4
Tier 2
PA
PREZCOBIX
Tier 3
PREZISTA
Tier 2
REBETOL
Tier 3
RELENZA DISKHALER
Tier 3
RESCRIPTOR
Tier 3
RETROVIR
Tier 3
#
PA; QL
PA; QL
#; QL
(Updated 07/01/15)
42
Drug Name
Drug Status
Drug Details
REYATAZ
Tier 2
RIBASPHERE ORAL CAPSULE
Tier 2
RIBASPHERE ORAL TABLET 200 MG
Tier 2
RIBASPHERE ORAL TABLET 400 MG, 600
MG
Tier 3
RIBATAB
Tier 3
ribavirin oral
Tier 1
rimantadine hcl
Tier 1
SELZENTRY
Tier 3
SOVALDI
Tier 2
stavudine
Tier 1
STRIBILD
Tier 3
SUSTIVA
Tier 2
TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75
MG
Tier 3
QL
TAMIFLU ORAL SUSPENSION
RECONSTITUTED 6 MG/ML
Tier 3
QL
TIVICAY
Tier 3
TRIUMEQ
Tier 3
TRIZIVIR
Tier 3
TRUVADA
Tier 2
PA
TYBOST
Tier 3
QL
TYZEKA
Tier 3
valacyclovir hcl oral
Tier 1
VALCYTE ORAL SOLUTION
RECONSTITUTED
Tier 2
QL
VALCYTE ORAL TABLET
Tier 2
QL
valganciclovir hcl
Tier 1
QL
VALTREX
Tier 3
ST; N1
VICTRELIS
Tier 3
PA; QL
VIDEX
Tier 2
VIDEX EC
Tier 3
VIEKIRA PAK
Tier 3
PA
VIRACEPT
Tier 3
#
VIRAMUNE ORAL SUSPENSION
Tier 3
VIRAMUNE ORAL TABLET
Tier 3
VIRAMUNE XR
Tier 3
VIRAZOLE
Tier 3
VIREAD
Tier 2
PA
PA
PA; ST
ST; N1
(Updated 07/01/15)
43
Drug Name
Drug Status
VISTIDE
Tier 3
VITEKTA
Tier 3
ZERIT ORAL CAPSULE
Tier 3
ZERIT ORAL SOLUTION RECONSTITUTED
Tier 3
ZIAGEN ORAL SOLUTION
Tier 3
ZIAGEN ORAL TABLET
Tier 3
zidovudine
Tier 1
ZOVIRAX ORAL CAPSULE
Tier 3
ZOVIRAX ORAL SUSPENSION
Tier 3
ZOVIRAX ORAL TABLET 800 MG
Tier 3
Drug Details
ST; N1
ST; N1
*ASSORTED CLASSES*
ARGYLE STERILE WATER
Tier 1
ASTAGRAF XL
Tier 3
ATGAM
Tier 3
AZASAN
Tier 3
azathioprine oral
Tier 1
BENLYSTA
Tier 3
CELLCEPT
Tier 3
CUPRIMINE
Tier 3
cyclosporine intravenous*
Tier 1
cyclosporine modified oral capsule 100 mg, 25 mg
Tier 1
cyclosporine modified oral solution
Tier 1
cyclosporine oral
Tier 1
DEPEN TITRATABS
Tier 2
GENGRAF
Tier 1
HECORIA
Tier 2
IMURAN
Tier 3
kalexate
Tier 1
KAYEXALATE
Tier 3
KIONEX
Tier 1
lactated ringers irrigation
Tier 1
mycophenolate mofetil
Tier 1
mycophenolic acid
Tier 1
NEORAL
Tier 3
NULOJIX
Tier 3
PHYSIOLYTE
Tier 1
PHYSIOSOL IRRIGATION
Tier 1
PROGRAF
Tier 3
PA
(Updated 07/01/15)
44
Drug Name
Drug Status
Drug Details
RAPAMUNE ORAL SOLUTION
Tier 3
RAPAMUNE ORAL TABLET 1 MG, 2 MG
Tier 3
#
REVLIMID
Tier 3
PA
ringers irrigation
Tier 1
SANDIMMUNE
Tier 3
SIMULECT
Tier 3
sirolimus oral
Tier 1
sodium polystyrene sulfonate oral
Tier 1
sodium polystyrene sulfonate suspension
Tier 1
SPS
Tier 3
sterile water for irrigation
Tier 1
SYPRINE
Tier 3
tacrolimus oral
Tier 1
THALOMID
Tier 3
THYMOGLOBULIN
Tier 3
TIS-U-SOL
Tier 1
XIAFLEX
Tier 2
ZORTRESS
Tier 3
*BETA BLOCKERS*
acebutolol hcl oral
Tier 1
atenolol oral
Tier 1
BETAPACE
Tier 3
BETAPACE AF
Tier 3
betaxolol hcl oral
Tier 1
bisoprolol fumarate
Tier 1
BYSTOLIC
Tier 2
carvedilol
Tier 1
COREG
Tier 3
COREG CR
Tier 2
CORGARD
Tier 3
INDERAL LA
Tier 3
INDERAL XL
Tier 3
KERLONE
Tier 3
labetalol hcl oral
Tier 1
LEVATOL
Tier 3
LOPRESSOR ORAL
Tier 3
metoprolol succinate er
Tier 3
metoprolol tartrate oral
Tier 1
LGC
LGC
LGC
LGC
(Updated 07/01/15)
45
Drug Name
Drug Status
nadolol oral
Tier 1
propranolol hcl er
Tier 1
propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 80
mg
Tier 1
propranolol hcl oral tablet 60 mg
Tier 1
SECTRAL
Tier 3
SORINE
Tier 1
sotalol hcl (af) oral tablet 120 mg
Tier 1
sotalol hcl (af) oral tablet 160 mg, 80 mg
Tier 1
sotalol hcl oral tablet 120 mg, 80 mg
Tier 1
sotalol hcl oral tablet 160 mg, 240 mg
Tier 1
SOTYLIZE
Tier 3
TENORMIN
Tier 3
TOPROL XL
Tier 3
TRANDATE
Tier 3
ZEBETA
Tier 3
Drug Details
LGC
LGC
LGC
*BIOLOGICALS MISC*
ADAGEN
Tier 3
PA
*CALCIUM CHANNEL BLOCKERS*
ADALAT CC
Tier 3
AFEDITAB CR
Tier 1
amlodipine besylate oral
Tier 1
CALAN
Tier 3
CALAN SR
Tier 3
CARDENE SR ORAL CAPSULE EXTENDED
RELEASE 12 HOUR 30 MG, 60 MG
Tier 3
CARDIZEM CD
Tier 3
CARDIZEM LA
Tier 3
CARDIZEM ORAL TABLET 120 MG, 30 MG,
60 MG
Tier 3
CARTIA XT
Tier 1
DILACOR XR
Tier 3
dilt-cd
Tier 1
diltiazem hcl cd
Tier 1
diltiazem hcl er
Tier 1
diltiazem hcl er beads
Tier 1
diltiazem hcl er coated beads
Tier 1
diltiazem hcl oral
Tier 1
dilt-xr
Tier 1
LGC
LGC
(Updated 07/01/15)
46
Drug Name
Drug Status
Drug Details
diltzac
Tier 1
felodipine er
Tier 1
ISOPTIN SR
Tier 3
MATZIM LA
Tier 1
nicardipine hcl oral
Tier 1
NIFEDIAC CC
Tier 1
NIFEDICAL XL
Tier 1
nifedipine er
Tier 1
nifedipine er osmotic
Tier 1
nifedipine oral
Tier 1
nimodipine oral
Tier 1
nisoldipine er oral tablet extended release 24 hr* 17
mg, 34 mg, 8.5 mg
Tier 1
NORVASC
Tier 3
ST; N1
NYMALIZE
Tier 3
PA; ST; N1; QL
PROCARDIA
Tier 3
PROCARDIA XL
Tier 3
SULAR ORAL TABLET EXTENDED
RELEASE 24 HR* 17 MG, 34 MG, 8.5 MG
Tier 3
TAZTIA XT
Tier 1
TIAZAC
Tier 3
verapamil hcl er oral capsule extended release 24
hour
Tier 1
verapamil hcl er oral tablet extendedrelease* 120 mg
Tier 1
verapamil hcl er oral tablet extendedrelease* 180 mg,
240 mg
Tier 1
verapamil hcl oral
Tier 1
VERELAN
Tier 3
VERELAN PM
Tier 3
LGC
LGC
*CARDIOTONICS*
DIGOX
Tier 1
digoxin oral tablet
Tier 1
LANOXIN ORAL
Tier 3
LGC
*CARDIOVASCULAR AGENTS - MISC.*
ADCIRCA
Tier 3
PA; QL
ADEMPAS
Tier 3
PA; QL
BIDIL
Tier 3
CAVERJECT
Tier 3
PA; #
CAVERJECT IMPULSE
Tier 3
PA; #
(Updated 07/01/15)
47
Drug Name
Drug Status
Drug Details
CORLANOR
Tier 3
PA; ST; QL
EDEX
Tier 3
PA
epoprostenol sodium
Tier 1
PA
LETAIRIS
Tier 2
PA
MUSE
Tier 3
PA
OPSUMIT
Tier 2
PA; QL
REMODULIN
Tier 3
PA
REVATIO INTRAVENOUS*
Tier 3
PA
REVATIO ORAL SUSPENSION
RECONSTITUTED
Tier 3
PA; QL
REVATIO ORAL TABLET
Tier 3
PA; QL
sildenafil citrate oral
Tier 1
PA; QL
TRACLEER
Tier 2
PA; #
TYVASO
Tier 3
PA
TYVASO REFILL
Tier 3
PA
TYVASO STARTER
Tier 3
PA
VELETRI
Tier 3
PA
VENTAVIS
Tier 3
PA
*CEPHALOSPORINS*
CEDAX
Tier 3
cefaclor oral capsule
Tier 1
cefadroxil
Tier 1
cefdinir
Tier 1
cefixime
Tier 1
cefpodoxime proxetil
Tier 1
cefprozil
Tier 1
CEFTIN ORAL SUSPENSION
RECONSTITUTED 250 MG/5ML
Tier 3
CEFTIN ORAL TABLET
Tier 3
cefuroxime axetil
Tier 1
cephalexin oral capsule
Tier 1
cephalexin oral suspension reconstituted
Tier 1
KEFLEX
Tier 3
SPECTRACEF
Tier 3
SUPRAX
Tier 3
*CONTRACEPTIVES*
ALTAVERA
CE
QL
alyacen 1/35
CE
QL
alyacen 7/7/7
Tier 1
PA; QL
(Updated 07/01/15)
48
Drug Name
Drug Status
Drug Details
AMETHIA
Tier 1
PA; QL
AMETHIA LO
Tier 1
PA; QL
APRI
CE
QL
ARANELLE
CE
QL
AUBRA
Tier 1
AVIANE
CE
QL
AZURETTE
CE
QL
BALZIVA
CE
QL
BEYAZ
Tier 3
BREVICON (28)
Tier 3
briellyn
CE
PA; QL
QL
CAMILA
Tier 1
PA; QL
CAMRESE
Tier 1
PA; QL
CAMRESE LO
Tier 1
PA; QL
CAZIANT
CE
QL
CESIA
CE
QL
CHATEAL
CE
QL
CRYSELLE-28
CE
QL
CYCLAFEM 1/35
CE
QL
CYCLAFEM 7/7/7
Tier 1
CYCLESSA
Tier 3
PA; QL
DASETTA 1/35
CE
QL
DASETTA 7/7/7
Tier 1
PA; QL
DAYSEE
Tier 1
PA; QL
DEPO-PROVERA INTRAMUSCULAR*
SUSPENSION 150 MG/ML
Tier 3
QL
DEPO-SUBQ PROVERA 104
Tier 3
QL
DESOGEN
Tier 3
desogestrel-ethinyl estradiol
Tier 1
PA; QL
drospirenone-ethinyl estradiol
Tier 1
PA; QL
ELINEST
CE
QL
ELLA
CE
QL
EMOQUETTE
CE
QL
ENPRESSE-28
CE
QL
ENSKYCE
Tier 1
PA; QL
ERRIN
Tier 1
PA; QL
ESTARYLLA
Tier 1
PA; QL
ESTROSTEP FE
Tier 3
FALMINA
CE
QL
(Updated 07/01/15)
49
Drug Name
Drug Status
Drug Details
FEMCON FE
Tier 3
GENERESS FE
Tier 3
#
GIANVI
Tier 1
PA; QL
GILDAGIA
CE
QL
GILDESS 1.5/30
CE
QL
GILDESS 1/20
CE
QL
GILDESS 24 FE
CE
GILDESS FE 1.5/30
CE
QL
GILDESS FE 1/20
CE
QL
HEATHER
Tier 1
PA; QL
IMPLANON
CE
QL
INTROVALE
Tier 1
PA; QL
JENCYCLA
Tier 1
PA; QL
JOLESSA
Tier 1
PA; QL
JOLIVETTE
Tier 1
PA; QL
JUNEL 1.5/30
CE
QL
JUNEL 1/20
CE
QL
JUNEL FE 1.5/30
CE
QL
JUNEL FE 1/20
CE
QL
KARIVA
CE
QL
KELNOR 1/35
CE
QL
KURVELO
CE
QL
LARIN 1/20
Tier 1
PA; QL
LARIN FE 1.5/30
Tier 1
PA; QL
LARIN FE 1/20
Tier 1
PA; QL
LEENA
CE
QL
LESSINA
CE
QL
LEVONEST
CE
QL
levonorgest-eth estrad 91-day oral tablet 0.1-0.02 &
0.01 mg, 0.15-0.03 mg
levonorgestrel oral tablet 0.75 mg
Tier 1
CE
PA; QL
QL
levonorgestrel-ethinyl estrad oral tablet 0.1-20
mg-mcg
Tier 1
levonorgestrel-ethinyl estrad oral tablet 0.15-30
mg-mcg
CE
QL
LEVORA 0.15/30 (28)
CE
QL
LILETTA
CE
LO LOESTRIN FE
Tier 3
LOESTRIN 1.5/30 (21)
Tier 3
PA; QL
(Updated 07/01/15)
50
Drug Name
Drug Status
Drug Details
LOESTRIN 1/20 (21)
Tier 3
LOESTRIN FE 1.5/30
Tier 3
LOESTRIN FE 1/20
Tier 3
LORYNA
Tier 1
PA; QL
LOSEASONIQUE
Tier 3
N1; QL
LOW-OGESTREL
CE
QL
LUTERA
CE
QL
LYZA
Tier 1
marlissa
CE
QL
medroxyprogesterone acetate intramuscular*
CE
PA; QL
MICROGESTIN 1.5/30
CE
QL
MICROGESTIN 1/20
CE
QL
MICROGESTIN FE 1.5/30
CE
QL
MICROGESTIN FE 1/20
CE
QL
MINASTRIN 24 FE
Tier 3
MIRCETTE
Tier 3
MIRENA
CE
PA; QL
#; QL
MODICON (28)
Tier 3
MONO-LINYAH
Tier 1
PA; QL
MONONESSA
Tier 1
PA; QL
MYZILRA
CE
NATAZIA
Tier 3
QL
NECON 0.5/35 (28)
CE
QL
NECON 1/35 (28)
CE
QL
NECON 1/50 (28)
Tier 3
NECON 10/11 (28)
CE
NECON 7/7/7
Tier 1
QL
PA; QL
NEXPLANON
CE
QL
NEXT CHOICE
CE
QL
NEXT CHOICE ONE DOSE
CE
QL
NORA-BE
Tier 1
norethin ace-eth estrad-fe oral tablet 1-20
mg-mcg(24)
Tier 1
norethindrone oral
Tier 1
norethin-eth estradiol-fe
PA; QL
PA; QL
CE
norgestimate-eth estradiol
Tier 1
PA; QL
norgestim-eth estrad triphasic
Tier 1
PA; QL
norgestrel-ethinyl estradiol
CE
QL
NORINYL 1+35 (28)
Tier 3
(Updated 07/01/15)
51
Drug Name
Drug Status
NORINYL 1+50 (28)
Tier 3
NOR-QD
Tier 3
Drug Details
NORTREL 0.5/35 (28)
CE
QL
NORTREL 1/35 (21)
CE
QL
NORTREL 1/35 (28)
CE
QL
NORTREL 7/7/7
Tier 1
PA; QL
NUVARING
Tier 2
QL
OCELLA
Tier 1
PA; QL
ORSYTHIA
CE
ORTHO EVRA
Tier 3
ORTHO MICRONOR
Tier 3
ORTHO TRI-CYCLEN (28)
Tier 3
ORTHO TRI-CYCLEN LO
Tier 3
ORTHO-CEPT (28)
Tier 3
ORTHO-CYCLEN (28)
Tier 3
ORTHO-NOVUM 1/35 (28)
Tier 3
ORTHO-NOVUM 7/7/7 (28)
Tier 3
OVCON-35 (28)
Tier 3
QL
#
PARAGARD INTRAUTERINE COPPER
CE
QL
PHILITH
CE
QL
PIMTREA
Tier 1
PA; QL
PIRMELLA 1/35
Tier 1
PA; QL
PIRMELLA 7/7/7
Tier 1
PA; QL
PORTIA-28
CE
QL
PREVIFEM
Tier 1
PA; QL
QUARTETTE
Tier 3
N1
QUASENSE
Tier 1
PA; QL
RECLIPSEN
CE
QL
SAFYRAL
Tier 3
SEASONIQUE
Tier 3
N1; QL
SKYLA
Tier 3
PA; QL
SOLIA
Tier 1
PA; QL
SPRINTEC 28
Tier 1
PA; QL
SRONYX
SYEDA
TILIA FE
TRI-ESTARYLLA
TRI-LEGEST FE
CE
Tier 1
CE
Tier 1
CE
QL
PA; QL
QL
PA; QL
QL
(Updated 07/01/15)
52
Drug Name
Drug Status
Drug Details
TRI-LINYAH
Tier 1
PA; QL
TRINESSA (28)
Tier 1
PA; QL
TRI-NORINYL (28)
Tier 3
TRI-PREVIFEM
Tier 1
PA; QL
TRI-SPRINTEC
Tier 1
PA; QL
TRIVORA (28)
CE
QL
VELIVET
CE
QL
VESTURA
Tier 1
viorele
VYFEMLA
CE
Tier 1
PA; QL
QL
PA; QL
WERA
CE
QL
WYMZYA FE
CE
QL
XULANE
CE
QL
YASMIN 28
Tier 3
YAZ
Tier 3
ZARAH
Tier 1
PA; QL
ZENCHENT
CE
QL
ZENCHENT FE
CE
QL
ZEOSA
CE
QL
ZOVIA 1/35E (28)
CE
QL
ZOVIA 1/50E (28)
CE
QL
*CORTICOSTEROIDS*
ASMALPRED
Tier 1
ASMALPRED PLUS
Tier 1
BAYCADRON
Tier 1
budesonide er
Tier 1
CORTEF
Tier 3
DEXAMETHASONE INTENSOL
Tier 3
dexamethasone oral elixir
Tier 1
dexamethasone oral tablet 0.5 mg, 0.75 mg, 1.5 mg,
4 mg, 6 mg
Tier 1
DEXPAK 10 DAY
Tier 3
DEXPAK 13 DAY
Tier 3
DEXPAK 6 DAY
Tier 3
ENTOCORT EC
Tier 3
FLO-PRED
Tier 3
fludrocortisone acetate oral
Tier 1
hydrocortisone oral
Tier 1
QL
ST; N1; QL
MEDROL (PAK)
Tier 3
(Updated 07/01/15)
53
Drug Name
Drug Status
Drug Details
MEDROL ORAL TABLET 16 MG, 2 MG, 32
MG, 4 MG
Tier 3
methylprednisolone (pak)
Tier 1
methylprednisolone oral
Tier 1
MILLIPRED
Tier 3
MILLIPRED DP
Tier 3
MILLIPRED DP 12-DAY
Tier 3
ORAPRED
Tier 3
ORAPRED ODT
Tier 3
PEDIAPRED
Tier 3
prednisolone oral
Tier 1
prednisolone sodium phosphate oral solution 15
mg/5ml, 6.7 (5 base) mg/5ml
Tier 1
prednisolone sodium phosphate oral tablet dispersible
Tier 1
prednisone (pak)
Tier 1
PREDNISONE INTENSOL
Tier 3
prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5
mg
Tier 1
PRELONE
Tier 3
RAYOS
Tier 3
ST; N1
UCERIS ORAL
Tier 3
PA; QL
VERIPRED 20
Tier 3
LGC
LGC
*COUGH/COLD/ALLERGY*
acetylcysteine inhalation
Tier 1
albatussin
Tier 3
albatussin nn oral liquid†
Tier 3
benzonatate
Tier 1
BROMFED DM
Tier 1
CARBAPHEN 12
Tier 3
CARBAPHEN 12 PED
Tier 3
cheratussin ac oral syrup
Tier 1
cheratussin dac
Tier 1
CLARINEX-D 12 HOUR
Tier 3
PA; QL
CLARINEX-D 24 HOUR
Tier 3
PA; QL
CPB WC
Tier 3
DECON-A ORAL ELIXIR
Tier 3
DECON-G
Tier 3
DIMETANE DX
Tier 1
EXACTUSS
Tier 3
(Updated 07/01/15)
54
Drug Name
Drug Status
Drug Details
fexofenadine-pseudoephed er
Tier 3
gani-tuss nr
Tier 1
GILPHEX TR
Tier 3
GILTUSS
Tier 3
GILTUSS PED-C
Tier 3
GILTUSS TR
Tier 3
guaiatussin ac
Tier 1
guaifenesin ac
Tier 1
guaifenesin dac
Tier 1
guaifenesin-codeine
Tier 1
hydrocod polst-cpm polst er
Tier 1
hydrocodone-homatropine
Tier 1
hydromet
Tier 1
HYPERSAL INHALATION NEBULIZATION
SOLUTION 3.5 %
Tier 3
iophen c-nr
Tier 1
m-clear wc
Tier 1
myci-gc
Tier 1
mytussin ac
Tier 1
mytussin dac
Tier 1
NEBUSAL INHALATION NEBULIZATION
SOLUTION 3 %
Tier 1
NEBUSAL INHALATION NEBULIZATION
SOLUTION 6 %
Tier 3
NEOTUSS PLUS
Tier 3
NEOTUSS-D ORAL LIQUID† 30-2-30-200
MG/5ML
Tier 3
nortuss-ex
Tier 3
OBREDON
Tier 3
PEDIATEX TDM
Tier 3
phenylhistine dh
Tier 3
promethazine-codeine
Tier 1
PA
promethazine-dm
Tier 1
PA
pseudoeph-bromphen-dm oral syrup
Tier 1
PULMOSAL
Tier 1
relcof c
Tier 1
RELHIST
Tier 3
RESCON-JR
Tier 3
RESCON-MX
Tier 3
(Updated 07/01/15)
55
Drug Name
Drug Status
REZIRA
Tier 3
robafen ac
Tier 1
ROMILAR AC
Tier 1
SEMPREX-D
Tier 3
sodium chloride inhalation nebulization solution 10
%, 3 %, 7 %
Tier 1
TESSALON PERLES
Tier 3
tgq 30pse/150gfn/15dm
Tier 3
tgq 30pse/3brm/15dm
Tier 3
TRICODE AR
Tier 3
TUSNEL ORAL CAPSULE
Tier 3
tusnel ped-c
Tier 3
TUSSICAPS
Tier 3
TUSSIGON
Tier 1
TUSSIONEX PENNKINETIC ER
Tier 3
TUSSO-DMR
Tier 3
virtussin a/c
Tier 1
VITUZ
Tier 3
Z-COF I
Tier 3
ZONATUSS
Tier 3
Drug Details
PA; QL
*DERMATOLOGICALS*
8-MOP
Tier 3
ABSORICA
Tier 3
PA; ST; QL
ACANYA
Tier 3
ST; N1
acitretin
Tier 1
ACLOVATE
Tier 3
ACTICIN
Tier 1
acyclovir external
Tier 1
ACZONE
Tier 3
adapalene external 0.1 %
Tier 3
PA
adapalene external cream
Tier 3
PA
adapalene external lotion
Tier 1
ST
aif #2 drug preparation kit
Tier 3
AKNE-MYCIN
Tier 3
ala quin
Tier 3
alclometasone dipropionate
Tier 1
ALCORTIN A
Tier 3
ALDARA
Tier 3
QL
ALICLEN
Tier 1
(Updated 07/01/15)
56
Drug Name
Drug Status
Drug Details
ALOQUIN
Tier 3
alphatrex
Tier 1
ALTABAX
Tier 3
ALUVEA
Tier 3
amcinonide external cream
Tier 1
AMNESTEEM
Tier 3
ANACAINE
Tier 3
antifungal external cream 2 %
Tier 1
APEXICON
Tier 1
APEXICON E
Tier 3
ATRALIN
Tier 3
AVAR
Tier 3
AVAR CLEANSER
Tier 1
AVAR LS
Tier 3
AVAR LS CLEANSER
Tier 3
AVAR-E EMOLLIENT
Tier 1
AVAR-E GREEN
Tier 1
AVAR-E LS
Tier 3
AVITA
Tier 1
AZELEX
Tier 3
BACTROBAN
Tier 3
baza antifungal
Tier 1
bensal hp
Tier 3
BENZAMYCIN
Tier 3
ST; N1
BENZAMYCINPAK
Tier 3
ST; N1
BENZEPRO
Tier 1
BENZEPRO SHORT CONTACT
Tier 1
BENZIQ
Tier 3
BENZIQ LS
Tier 3
benzoyl peroxide external foam
Tier 1
benzoyl peroxide short contact
Tier 1
benzoyl peroxide-erythromycin
Tier 1
betamethasone dipropionate aug
Tier 1
betamethasone dipropionate external
Tier 1
betamethasone valerate external
Tier 1
BOTOX COSMETIC
Tier 2
bp 10-1
Tier 1
bp cleansing wash
Tier 1
PA; ST; N1; QL
PA; ST; N1; #
PA
PA
(Updated 07/01/15)
57
Drug Name
Drug Status
bp foam
Tier 1
bpo
Tier 3
bpo foaming cloths
Tier 3
calcipotriene external
Tier 1
CALCITRENE
Tier 1
CAPEX
Tier 3
CARAC
Tier 3
CARRINGTON ANTIFUNGAL
Tier 1
CEM-UREA
Tier 3
CENTANY
Tier 3
CERISA WASH
Tier 1
CEROVEL
Tier 1
CICLODAN EXTERNAL CREAM
Tier 1
CICLODAN EXTERNAL SOLUTION
Tier 1
ciclopirox external
Tier 1
ciclopirox external shampoo
Tier 1
ciclopirox external solution
Tier 1
ciclopirox olamine external
Tier 1
CLARAVIS
Tier 1
CLARIS CLARIFYING WASH
Tier 1
CLENIA
Tier 1
CLENIA FOAMING WASH
Tier 1
CLEOCIN-T
Tier 3
CLINDACIN ETZ EXTERNAL SWAB
Tier 1
CLINDACIN-P
Tier 1
CLINDAGEL
Tier 3
CLINDAMAX
Tier 1
clindamycin phos-benzoyl perox
Tier 1
clindamycin phosphate external
Tier 1
clobetasol propionate e
Tier 1
clobetasol propionate emulsion
Tier 1
clobetasol propionate external
Tier 1
CLOBEX
Tier 3
CLOBEX SPRAY
Tier 2
clotrimazole-betamethasone
Tier 1
CNL8 NAIL
Tier 3
CONDYLOX
Tier 3
CORDRAN EXTERNAL LOTION
Tier 3
Drug Details
PA
PA
PA; ST; N1; QL
ST; N1
(Updated 07/01/15)
58
Drug Name
Drug Status
Drug Details
CORDRAN EXTERNAL TAPE
Tier 3
CORMAX
Tier 1
CORMAX SCALP APPLICATION
Tier 1
CORTALO
Tier 1
CORTANE-B EXTERNAL
Tier 3
CORTISPORIN EXTERNAL
Tier 3
COSENTYX
Tier 3
PA
COSENTYX SENSOREADY PEN
Tier 3
PA
CUTIVATE
Tier 3
ST; N1
DENAVIR
Tier 3
DERMA-SMOOTHE/FS BODY
Tier 3
DERMA-SMOOTHE/FS SCALP
Tier 3
DERMASORB AF
Tier 3
DERMASORB XM
Tier 3
DERMATOP EXTERNAL CREAM
Tier 3
DERMAZENE
Tier 1
DESONATE
Tier 3
desonide external
Tier 1
DESOWEN
Tier 3
desoximetasone external
Tier 1
desoximetasone external cream 0.25 %
Tier 1
desoximetasone external ointment 0.25 %
Tier 1
diclofenac sodium transdermal
Tier 1
DIFFERIN EXTERNAL 0.1 %
Tier 3
PA; ST; N1
DIFFERIN EXTERNAL 0.3 %
Tier 3
PA; ST
DIFFERIN EXTERNAL CREAM
Tier 3
PA; ST; N1
DIFFERIN EXTERNAL LOTION
Tier 3
PA; ST; N1
diflorasone diacetate external ointment
Tier 1
DIPROLENE
Tier 3
DIPROLENE AF
Tier 3
DOVONEX EXTERNAL CREAM
Tier 3
doxycycline
Tier 1
DRITHO-CREME HP
Tier 3
DUAC
Tier 3
econazole nitrate external
Tier 1
ECOZA
Tier 3
EFUDEX
Tier 3
ELIDEL
Tier 2
ST; N1
PA
ST; N1
PA
(Updated 07/01/15)
59
Drug Name
Drug Status
ELIMITE
Tier 3
ELOCON
Tier 3
EMLA
Tier 3
EPIDUO
Tier 2
EPIFOAM
Tier 3
ERTACZO
Tier 3
ery
Tier 1
ERYGEL
Tier 3
erythromycin external pad
Tier 1
erythromycin external solution
Tier 1
EURAX
Tier 3
EVOCLIN
Tier 3
EXELDERM
Tier 3
EXODERM EXTERNAL LOTION
Tier 1
EXTINA
Tier 3
FABIOR
Tier 3
FINACEA
Tier 3
FLECTOR
Tier 2
fluocinolone acetonide body
Tier 1
fluocinolone acetonide external
Tier 1
fluocinolone acetonide scalp
Tier 1
fluocinonide external
Tier 1
fluocinonide external cream 0.05 %
Tier 1
fluocinonide external ointment
Tier 1
fluocinonide external solution
Tier 1
fluocinonide-e
Tier 1
FLUOROPLEX
Tier 3
fluorouracil external
Tier 1
fluticasone propionate external
Tier 1
GEBAUERS PAIN EASE
Tier 3
GEBAUERS SPRAY AND STRETCH
Tier 3
gentamicin sulfate external
Tier 1
GORDOFILM
Tier 3
GORDONS UREA EXTERNAL OINTMENT 40
%
Tier 3
grafco silver nit applicator
Tier 1
halobetasol propionate
Tier 1
HALOG
Tier 3
Drug Details
PA
PA; ST; N1
QL
LGC
LGC
LGC
HALOTIN
Tier 3
(Updated 07/01/15)
60
Drug Name
Drug Status
Drug Details
hydrocortisone ace-pramoxine external
Tier 1
hydrocortisone acetate-aloe external
Tier 1
hydrocortisone butyr lipo base
Tier 1
hydrocortisone butyrate external
Tier 1
hydrocortisone external cream 2.5 %
Tier 1
hydrocortisone external lotion 2.5 %
Tier 1
hydrocortisone external ointment 2.5 %
Tier 1
hydrocortisone valerate
Tier 1
hydrocortisone-iodoquinol
Tier 1
hygel
Tier 1
HYLIRA EXTERNAL LOTION
Tier 3
HYPERCARE
Tier 1
imiquimod external
Tier 1
QL
JUBLIA
Tier 3
PA
KENALOG EXTERNAL
Tier 3
KERAFOAM
Tier 3
KERAFOAM 42
Tier 3
KERALAC
Tier 3
KERYDIN
Tier 3
ketoconazole external cream
Tier 1
ketoconazole external shampoo
Tier 1
KETODAN EXTERNAL FOAM
Tier 1
KLARON
Tier 3
kp miconazole nitrate
Tier 1
lactic acid external
Tier 1
LATRIX
Tier 1
lavare wound wash
Tier 3
LEVULAN KERASTICK
Tier 3
lidocaine external ointment
Tier 1
lidocaine external patch
Tier 1
lidocaine hcl external cream
Tier 1
lidocaine hcl external solution
Tier 1
lidocaine-prilocaine external cream
Tier 1
LIDODERM
Tier 3
PA
lidopin external cream 3 %
Tier 3
ST
lidorx
Tier 3
lindane external
Tier 1
LOCOID
Tier 3
PA
ST; N1
(Updated 07/01/15)
61
Drug Name
Drug Status
LOCOID LIPOCREAM
Tier 3
LOKARA
Tier 1
LOPROX
Tier 3
LOTRISONE
Tier 3
LUXIQ
Tier 3
LUZU
Tier 3
mafenide acetate external
Tier 1
malathion external
Tier 1
METROCREAM
Tier 3
METROGEL
Tier 3
METROLOTION
Tier 3
metronidazole external
Tier 1
METVIXIA
Tier 3
MEXAR WASH
Tier 1
micaderm
Tier 1
MICATIN
Tier 3
miconazole nitrate external cream
Tier 1
MICRO GUARD EXTERNAL CREAM
Tier 1
MIRVASO
Tier 3
mometasone furoate external
Tier 1
mupirocin calcium
Tier 1
mupirocin external
Tier 1
MYORISAN
Tier 3
NAFTIN
Tier 3
NATROBA
Tier 3
NEOSPORIN AF
Tier 1
NIZORAL
Tier 3
NORITATE
Tier 3
NOVACORT
Tier 3
NUCORT
Tier 3
NUOX
Tier 3
NUZOLE
Tier 1
NYAMYC
Tier 1
nystatin external cream
Tier 1
nystatin external ointment
Tier 1
nystatin external powder 100000 unit/gm
Tier 1
nystatin-triamcinolone
Tier 1
NYSTOP
Tier 1
Drug Details
ST; N1
ST; N1
ST; N1
PA; ST; N1; QL
(Updated 07/01/15)
62
Drug Name
Drug Status
Drug Details
OLUX
Tier 3
ST; N1
OLUX-E
Tier 3
ST; N1
ONEXTON
Tier 3
ST
OPTASE
Tier 3
ORACEA
Tier 2
OVACE PLUS EXTERNAL CREAM
Tier 3
OVACE PLUS EXTERNAL SHAMPOO
Tier 3
OVACE PLUS WASH
Tier 3
OVACE WASH
Tier 3
OVIDE
Tier 3
OXISTAT
Tier 3
OXSORALEN ULTRA
Tier 3
PANDEL
Tier 3
PANRETIN
Tier 2
pedi-dri
Tier 1
PENLAC
Tier 3
PA
PENNSAID TRANSDERMAL SOLUTION 1.5
%, 2 %
Tier 3
ST; N1; QL
permethrin external cream
Tier 1
PICATO
Tier 2
PLEXION
Tier 3
PLEXION CLEANSER EXTERNAL LIQUID†
Tier 3
PLEXION CLEANSING CLOTH EXTERNAL
PAD
Tier 3
PLIAGLIS
Tier 3
podactin external cream
Tier 1
podocon
Tier 3
podofilox external
Tier 1
PRAMOSONE E
Tier 3
PRAMOSONE EXTERNAL CREAM 1-1 %
Tier 3
PRAMOSONE EXTERNAL LOTION
Tier 3
PRAMOSONE EXTERNAL OINTMENT
Tier 3
PRASCION
Tier 1
PRASCION FC
Tier 1
PRASCION RA
Tier 1
prednicarbate
Tier 1
PROTOPIC
Tier 2
PRUDOXIN
Tier 3
QUTENZA
Tier 3
PA
QL
PA; #
(Updated 07/01/15)
63
Drug Name
Drug Status
Drug Details
QUTENZA (2 PATCH)
Tier 3
ra antifungal external cream
Tier 1
RE 10 WASH
Tier 1
REGENECARE
Tier 3
REGRANEX
Tier 3
REMEDY ANTIFUNGAL EXTERNAL
CREAM
Tier 1
REMEVEN
Tier 1
RETIN-A
Tier 3
PA; ST; N1
RETIN-A MICRO
Tier 2
PA
RETIN-A MICRO PUMP EXTERNAL 0.04 %,
0.1 %
Tier 2
PA
REVINA
Tier 1
RIAX
Tier 3
ROSADAN EXTERNAL
Tier 1
ROSADAN EXTERNAL CREAM
Tier 1
ROSANIL CLEANSER
Tier 1
SALACYN
Tier 1
salicylic acid external cream
Tier 1
salicylic acid external foam
Tier 1
salicylic acid external liquid† 27.5 %
Tier 1
salicylic acid external lotion
Tier 1
salicylic acid external shampoo
Tier 1
salicylic acid wart remover
Tier 1
SALKERA
Tier 3
SALVAX DUO PLUS
Tier 3
SANTYL
Tier 3
scalacort
Tier 1
se 10-5 ss
Tier 1
SEB-PREV
Tier 3
SEB-PREV WASH
Tier 1
SECURA ANTIFUNGAL
Tier 1
SECURA ANTIFUNGAL EXTRA THICK
Tier 1
selenium sulfide external lotion
Tier 1
SELRX
Tier 3
SILVADENE
Tier 3
silver sulfadiazine external
Tier 1
SKLICE
Tier 3
sm antifungal miconazole
Tier 1
ST; N1
(Updated 07/01/15)
64
Drug Name
Drug Status
sodium hyaluronate external
Tier 1
sodium sulfacetamide
Tier 1
sodium sulfacetamide wash
Tier 3
SOLARAZE
Tier 3
SOOLANTRA
Tier 3
SOOTHE & COOL INZO ANTIFUNGAL
Tier 1
SORIATANE
Tier 2
SORILUX
Tier 3
SSD
Tier 1
SSD AF
Tier 1
sss 10-5
Tier 1
STELARA
Tier 2
sulfacetamide sodium (acne)
Tier 1
sulfacetamide sodium external
Tier 1
sulfacetamide sodium-sulfur external cream 10-2 %,
10-5 %
Tier 1
sulfacetamide sodium-sulfur external cream 9.8-4.8
%
Tier 1
sulfacetamide sodium-sulfur external emulsion
Tier 1
sulfacetamide sodium-sulfur external foam
Tier 1
sulfacetamide sodium-sulfur external liquid† 10-2 %,
9-4 %, 9-4.5 %
Tier 1
sulfacetamide sodium-sulfur external liquid† 9.8-4.8
%
Tier 1
sulfacetamide sodium-sulfur external lotion 10-5 %
Tier 1
sulfacetamide sodium-sulfur external lotion 9.8-4.8
%
Tier 1
sulfacetamide sodium-sulfur external pad
Tier 1
sulfacetamide sodium-sulfur external suspension 8-4
%
Tier 1
sulfacetamide sod-sulfur wash external emulsion
Tier 1
SULFACLEANSE 8/4
Tier 1
SULFAMYLON
Tier 3
SULFOAM
Tier 3
SUPHERA
Tier 1
SYNALAR
Tier 3
SYNERA
Tier 3
TACLONEX
Tier 3
tacrolimus external
Tier 1
TARGRETIN EXTERNAL
Tier 2
Drug Details
ST
ST; N1
PA
PA
PA
PA
PA; QL
(Updated 07/01/15)
65
Drug Name
Drug Status
Drug Details
TAZORAC
Tier 2
tbc
Tier 1
TEMOVATE
Tier 3
TEMOVATE E
Tier 3
TERSI
Tier 3
TEXACORT
Tier 3
THERMAZENE
Tier 1
tl urea
Tier 1
TOPICORT
Tier 3
TOPICORT SPRAY
Tier 3
tretinoin external
Tier 1
PA
tretinoin microsphere
Tier 1
PA
tretinoin microsphere pump
Tier 1
PA
TRETIN-X EXTERNAL CREAM
Tier 3
PA; ST; N1
triamcinolone acetonide external aerosol, solution
Tier 1
triamcinolone acetonide external cream
Tier 1
triamcinolone acetonide external lotion
Tier 1
triamcinolone acetonide external ointment
Tier 1
TRIANEX
Tier 3
TRI-CHLOR
Tier 3
TRIDERM
Tier 1
U-CORT
Tier 1
U-KERA E
Tier 1
ULESFIA
Tier 3
ULTRAVATE
Tier 3
UMECTA EXTERNAL EMULSION
Tier 3
UMECTA PD
Tier 3
URAMAXIN EXTERNAL FOAM
Tier 3
urea external
Tier 1
urea external cream 39 %, 40 %, 45 %, 50 %
Tier 1
urea external emulsion
Tier 1
urea external lotion 40 %, 45 %
Tier 1
urea external suspension
Tier 1
urea hydrating
Tier 1
urea in zn undecyl-lactic acid
Tier 1
urea nail external
Tier 1
urea nail external kit
Tier 3
urea nail external stick
Tier 3
PA
LGC
LGC
(Updated 07/01/15)
66
Drug Name
Drug Status
Drug Details
urea nail film
Tier 1
urea-c40
Tier 1
UTOPIC
Tier 3
VALCHLOR
Tier 3
VANOXIDE-HC
Tier 3
VASOLEX
Tier 1
VECTICAL
Tier 3
VERDESO
Tier 3
VEREGEN
Tier 3
VERSICLEAR
Tier 1
virti-sulf
Tier 1
VITAZOL
Tier 1
VOLTAREN TRANSDERMAL
Tier 2
VUSION
Tier 3
VYTONE
Tier 3
WESTCORT
Tier 3
XERAC AC
Tier 3
XERESE
Tier 3
XOLEGEL
Tier 3
X-VIATE
Tier 1
XYLOCAINE EXTERNAL
Tier 3
zaclir cleansing external lotion 8 %
Tier 3
ZENATANE ORAL CAPSULE 10 MG, 20 MG,
40 MG
Tier 3
ZENCIA
Tier 1
ZITHRANOL
Tier 3
ZITHRANOL-RR
Tier 3
ZONALON
Tier 3
ZOVIRAX EXTERNAL
Tier 3
ZYCLARA
Tier 3
PA; QL
ZYCLARA PUMP EXTERNAL CREAM 2.5 %,
3.75 %
Tier 3
PA; QL
ACCU-CHEK ACTIVE
Tier 3
PA; ST; QL
ACCU-CHEK AVIVA IN VITRO STRIP
Tier 3
PA; ST; QL
ACCU-CHEK AVIVA PLUS IN VITRO
Tier 3
PA; ST; QL
ACCU-CHEK COMFORT CURVE IN VITRO
STRIP
Tier 3
PA; ST; QL
ACCU-CHEK COMPACT
Tier 3
PA; ST; QL
PA
ST; N1
N1; QL
PA; ST; N1; QL
*DIAGNOSTIC PRODUCTS*
(Updated 07/01/15)
67
Drug Name
Drug Status
Drug Details
ACCU-CHEK COMPACT PLUS
Tier 3
PA; ST; QL
ACCU-CHEK COMPACT TEST DRUM
Tier 3
PA; ST; QL
ACCU-CHEK SMARTVIEW
Tier 3
PA; ST; QL
ACCUTREND GLUCOSE
Tier 3
PA; ST; QL
ACETEST
Tier 3
active-medicated spec collect
Tier 3
ACURA BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
ADVANCE INTUITION TEST
Tier 3
PA; ST; QL
ADVANCE MICRO-DRAW TEST
Tier 3
PA; ST; QL
ADVOCATE REDI-CODE IN VITRO
Tier 3
PA; ST; QL
ADVOCATE REDI-CODE+ TEST
Tier 3
PA; ST; QL
ADVOCATE TEST
Tier 3
PA; ST; QL
AGAMATRIX AMP TEST
Tier 3
PA; ST; QL
AGAMATRIX JAZZ TEST
Tier 3
PA; ST; QL
AGAMATRIX KEYNOTE TEST
Tier 3
PA; ST; QL
AGAMATRIX PRESTO TEST
Tier 3
PA; ST; QL
albertsons test
Tier 3
PA; ST; QL
ALBUSTIX
Tier 3
ARIDOL
Tier 3
ASCENSIA AUTODISC TEST
Tier 3
ASSURE 3 TEST
Tier 3
PA; ST; QL
ASSURE 4 TEST
Tier 3
PA; ST; QL
ASSURE II
Tier 3
PA; ST; QL
ASSURE II CHECK
Tier 3
PA; ST; QL
ASSURE PLATINUM
Tier 3
PA; ST; QL
ASSURE PRO TEST
Tier 3
PA; ST; QL
AT LAST TEST
Tier 3
PA; ST; QL
BAR-TEST
Tier 3
BAYER BREEZE 2 TEST
Tier 3
BAYER CONTOUR NEXT TEST
Tier 3
PA; ST; QL
BAYER CONTOUR TEST
Tier 3
PA; ST; QL
BD TEST
Tier 3
PA; ST; QL
BG STAR TEST
Tier 3
PA; ST; QL
BIOSCANNER GLUCOSE TEST
Tier 3
PA; ST; QL
bl test strip pack
Tier 3
PA; ST; QL
blood glucose test
Tier 3
PA; ST; QL
CAREONE BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
CARESENS N GLUCOSE TEST
Tier 3
PA; ST; QL
(Updated 07/01/15)
68
Drug Name
Drug Status
Drug Details
CHEK-STIX CONTROL
Tier 3
CHEMSTRIP 10 MD
Tier 3
CHEMSTRIP 10/SG
Tier 3
CHEMSTRIP 2 GP
Tier 3
CHEMSTRIP 5 OB
Tier 3
CHEMSTRIP 7
Tier 3
CHEMSTRIP 9
Tier 3
CHEMSTRIP K
Tier 3
CHEMSTRIP MICRAL
Tier 3
CHEMSTRIP UGK
Tier 3
CHOICE DM FORA G20 TEST STRIPS
Tier 3
PA; ST; QL
CLEVER CHEK AUTO-CODE TEST
Tier 3
PA; ST; QL
CLEVER CHEK AUTO-CODE VOICE IN
VITRO
Tier 3
PA; ST; QL
CLEVER CHEK TEST
Tier 3
PA; ST; QL
CLEVER CHOICE AUTO-CODE TEST
Tier 3
PA; ST; QL
CLEVER CHOICE MICRO TEST
Tier 3
PA; ST; QL
CLINISTIX
Tier 3
CLINITEST
Tier 3
COMBISTIX
Tier 3
CONTROL AST
Tier 3
PA; ST; QL
CONTROL TEST
Tier 3
PA; ST; QL
CVS ADVANCED GLUCOSE TEST
Tier 3
PA; ST; QL
cvs blood glucose test
Tier 3
PA; ST; QL
CVS KETONE CARE
Tier 3
CYSTO-CONRAY II
Tier 3
CYSTOGRAFIN-DILUTE
Tier 3
diabetic.com test
Tier 3
DIASTIX
Tier 3
diatrue plus test
Tier 3
DIGIBAR 190
Tier 3
discount drug mart test
Tier 3
PA; ST; QL
drug emporium test
Tier 3
PA; ST; QL
duane reade test
Tier 3
PA; ST; QL
DUO-CARE TEST
Tier 3
PA; ST; QL
easy plus blood glucose test
Tier 3
PA; ST; QL
easy plus ii glucose test
Tier 3
PA; ST; QL
EASY STEP TEST
Tier 3
PA; ST; QL
PA; ST; QL
PA; ST; QL
easy talk blood glucose test
Tier 3
PA; ST; QL
(Updated 07/01/15)
69
Drug Name
Drug Status
Drug Details
EASY TOUCH HEALTHPRO TEST
Tier 3
PA; ST; QL
EASY TOUCH TEST
Tier 3
PA; ST; QL
easy trak blood glucose test
Tier 3
PA; ST; QL
EASYGLUCO IN VITRO
Tier 3
PA; ST; QL
EASYMAX 15 TEST
Tier 3
PA; ST; QL
EASYMAX TEST
Tier 3
PA; ST; QL
easyplus blood glucose test
Tier 3
PA; ST; QL
EASYPRO BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
EASYPRO PLUS IN VITRO
Tier 3
PA; ST; QL
ECLIPSE TEST
Tier 3
PA; ST; QL
element compact test
Tier 3
PA; ST; QL
ELEMENT PLUS TEST
Tier 3
PA; ST; QL
ELEMENT TEST
Tier 3
PA; ST; QL
EMBRACE BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
EMBRACE EVO BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
EMBRACE PRO GLUCOSE TEST
Tier 3
PA; ST; QL
ENTERO VU
Tier 3
ENVISION AUTOCODE TEST
Tier 3
PA; ST; QL
EQL TRUETEST TEST
Tier 3
PA; ST; QL
EQL TRUETRACK TEST
Tier 3
PA; ST; QL
EVENCARE + BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
EVENCARE BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
EVENCARE G2 TEST
Tier 3
PA; ST; QL
EVENCARE G3 TEST
Tier 3
PA; ST; QL
EVOLUTION AUTOCODE IN VITRO
Tier 3
PA; ST; QL
EXACTECH R-S-G TEST
Tier 3
PA; ST; QL
EXACTECH TEST
Tier 3
PA; ST; QL
express med test strip pack
Tier 3
PA; ST; QL
EZ SMART BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
EZ SMART PLUS GLUCOSE TEST
Tier 3
PA; ST; QL
E-Z-CAT DRY
Tier 3
E-Z-DISK
Tier 3
E-Z-DOSE
Tier 3
E-Z-HD
Tier 3
E-Z-PAQUE
Tier 3
E-Z-PASTE
Tier 3
FASTTAKE TEST
Tier 3
PA; ST; QL
FIFTY50 GLUCOSE TEST 2.0
Tier 3
PA; ST; QL
(Updated 07/01/15)
70
Drug Name
Drug Status
Drug Details
FORA D10 BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
FORA D15C BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
FORA D15G BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
FORA D15Z BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
FORA D20 BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
FORA G20 BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
FORA G30A BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
FORA G71A BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
FORA G90 BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
FORA GD20 TEST
Tier 3
PA; ST; QL
FORA V10 BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
Tier 3
PA; ST; QL
Tier 3
PA; ST; QL
Tier 3
PA; ST; QL
FORA V30A BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
FORACARE GD40 TEST
Tier 3
PA; ST; QL
FORACARE PREMIUM V10 TEST
Tier 3
PA; ST; QL
FORACARE TEST N GO TEST
Tier 3
PA; ST; QL
FREESTYLE INSULINX TEST
Tier 3
PA; ST; N1; QL
FREESTYLE LITE TEST
Tier 3
PA; ST; N1; QL
FREESTYLE TEST
Tier 3
PA; ST; N1; QL
GASTROGRAFIN
Tier 3
GASTROMARK
Tier 3
ge100 blood glucose test
Tier 3
QL
ght test
Tier 3
PA; ST; QL
giant eagle pharm test
Tier 3
QL
GLUCO PERFECT 3 TEST
Tier 3
QL
GLUCOCARD 01 SENSOR PLUS
Tier 3
QL
GLUCOCARD EXPRESSION TEST
Tier 3
QL
GLUCOCARD SHINE TEST
Tier 3
QL
GLUCOCARD VITAL TEST
Tier 3
QL
GLUCOCARD X-SENSOR
Tier 3
QL
GLUCOCOM TEST
Tier 3
QL
GLUCOLAB TEST
Tier 3
QL
GLUCONAVII BLOOD GLUCOSE TEST
Tier 3
QL
GLUCOSTIX
Tier 3
QL
GMATE BLOOD GLUCOSE TEST
Tier 3
QL
HEALTH ALLIANCE
Tier 3
QL
(Updated 07/01/15)
71
Drug Name
Drug Status
Drug Details
HEMA-COMBISTIX
Tier 3
HYSKON
Tier 3
INFINITY BLOOD GLUCOSE TEST
Tier 3
QL
kerr drug test strip pack
Tier 3
QL
KETOCARE
Tier 3
KETO-DIASTIX
Tier 3
KETOSTIX
Tier 3
kinray test
Tier 3
QL
kroger blood glucose test
Tier 3
QL
kroger premium glucose test
Tier 3
QL
kroger test
Tier 3
QL
LABSTIX
Tier 3
LIBERTY NEXT GENERATION TEST
Tier 3
QL
liberty test
Tier 3
QL
life medical test
Tier 3
QL
LIQUID E-Z-PAQUE
Tier 3
LIQUID POLIBAR
Tier 3
LIQUID POLIBAR PLUS
Tier 3
long test
Tier 3
MAXIBAR
Tier 3
MAXIMA BLOOD GLUCOSE TEST
Tier 3
MD-GASTROVIEW
Tier 1
meijer blood glucose test
Tier 3
PA; ST; QL
meijer premium glucose test
Tier 3
PA; ST; QL
meijer test
Tier 3
PA; ST; QL
MEIJER TRUETEST TEST
Tier 3
PA; ST; QL
MEIJER TRUETRACK TEST
Tier 3
PA; ST; QL
METOPIRONE
Tier 3
MICRO-BUMINTEST
Tier 3
MICRODOT TEST
Tier 3
MULTISTIX
Tier 3
MULTISTIX 10 SG
Tier 3
MULTISTIX 5
Tier 3
MULTISTIX 7
Tier 3
MULTISTIX 8
Tier 3
MULTISTIX 9
Tier 3
MULTISTIX 9 SG
Tier 3
MYGLUCOHEALTH TEST
Tier 3
QL
PA; ST; QL
PA; ST; QL
PA; ST; QL
(Updated 07/01/15)
72
Drug Name
Drug Status
Drug Details
NAVARRO BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
NEUTEK 2TEK TEST
Tier 3
PA; ST; QL
NEXGEN TEST
Tier 3
PA; ST; QL
NOVA MAX GLUCOSE TEST
Tier 3
PA; ST; QL
ON CALL EXPRESS BLOOD GLUCOSE
Tier 3
PA; ST; QL
ON CALL PLUS BLOOD GLUCOSE
Tier 3
PA; ST; QL
ON CALL VIVID BLOOD GLUCOSE
Tier 3
PA; ST; QL
ONETOUCH TEST
Tier 2
QL
ONETOUCH ULTRA BLUE
Tier 2
QL
ONETOUCH VERIO IN VITRO STRIP
Tier 2
QL
OPTIUM TEST
Tier 3
PA; ST; QL
OPTIUMEZ TEST
Tier 3
PA; ST; QL
OPTUMRX BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
PHARMACIST CHOICE AUTOCODE
Tier 3
PA; ST; QL
POCKETCHEM EZ TEST
Tier 3
PA; ST; QL
POLIBAR ACB
Tier 3
PRECISION PCX
Tier 3
PA; ST; N1; QL
PRECISION PCX PLUS TEST
Tier 3
PA; ST; N1; QL
PRECISION POINT OF CARE TEST
Tier 3
PA; ST; N1; QL
PRECISION QID TEST
Tier 3
PA; ST; N1; QL
PRECISION SOF-TACT TEST
Tier 3
PA; ST; N1; QL
PRECISION XTRA BLOOD GLUCOSE
Tier 3
PA; ST; N1; QL
prestige smart system test
Tier 3
PA; ST; QL
PRESTIGE TEST
Tier 3
PA; ST; QL
PRESTIGE VALUE PACK
Tier 3
PA; ST; QL
PRODIGY AUTOCODE BLOOD GLUCOSE IN
VITRO
Tier 3
PA; ST; QL
PRODIGY NO CODING BLOOD GLUC
Tier 3
PA; ST; QL
PROVOCHOLINE
Tier 3
PTS PANELS GLUCOSE TEST
Tier 3
PA; ST; QL
QUICKTEK TEST
Tier 3
PA; ST; QL
QUINTET AC BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
QUINTET BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
RA TRUETEST TEST
Tier 3
PA; ST; QL
READI-CAT
Tier 3
READI-CAT 2
Tier 3
REFUAH PLUS BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
RELION BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
RELION CONFIRM/MICRO TEST
Tier 3
PA; ST; QL
(Updated 07/01/15)
73
Drug Name
Drug Status
Drug Details
RELION KETONE
Tier 3
RELION PRIME TEST
Tier 3
PA; ST; QL
RELION ULTIMA TEST
Tier 3
PA; ST; QL
REVEAL BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
REXALL BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
RIGHTEST GS100 BLOOD GLUCOSE
Tier 3
PA; ST; QL
Tier 3
PA; ST; QL
Tier 3
PA; ST; QL
sentry test
Tier 3
PA; ST; QL
shoprite test
Tier 3
PA; ST; QL
SITZMARKS
Tier 3
SMART DIABETES XPRES TEST
Tier 3
PA; ST; QL
SMART SENSE PREMIUM TEST
Tier 3
PA; ST; QL
SMART SENSE VALUE TEST
Tier 3
PA; ST; QL
SMARTEST BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
SOLUS V2 TEST
Tier 3
PA; ST; QL
SUPREME TEST
Tier 3
PA; ST; QL
SURE EDGE TEST
Tier 3
PA; ST; QL
SURECHEK BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
SURESTEP PRO TEST
Tier 3
PA; ST; QL
SURESTEP TEST
Tier 3
PA; ST; QL
SURE-TEST EASYPLUS MINI TEST
Tier 3
PA; ST; QL
T.R.U.E. TEST
Tier 3
TAGITOL V
Tier 3
TELCARE BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
tgt blood glucose test
Tier 3
PA; ST; QL
THYROGEN
Tier 2
true care test strip pack
Tier 3
PA; ST; QL
TRUE METRIX BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
TRUETEST TEST
Tier 3
PA; ST; QL
TRUETRACK TEST
Tier 3
PA; ST; QL
ULTIMA TEST
Tier 3
PA; ST; QL
ULTRATRAK PRO TEST
Tier 3
PA; ST; QL
ULTRATRAK ULTIMATE TEST
Tier 3
PA; ST; QL
UNISTRIP1 GENERIC
Tier 3
PA; ST; QL
URISTIX
Tier 3
URISTIX 4
Tier 3
VARIBAR HONEY
Tier 3
(Updated 07/01/15)
74
Drug Name
Drug Status
Drug Details
VARIBAR NECTAR
Tier 3
VARIBAR PUDDING
Tier 3
VARIBAR THIN HONEY
Tier 3
VARIBAR THIN LIQUID
Tier 3
VICTORY AGM-4000 TEST
Tier 3
PA; ST; QL
VOCAL POINT BLOOD GLUCOSE TEST
Tier 3
PA; ST; QL
VOLUMEN
Tier 3
WAVESENSE PRESTO
Tier 3
PA; ST; QL
winn dixie medic test
Tier 3
PA; ST; QL
*DIGESTIVE AIDS*
CREON
Tier 2
PANCREAZE
Tier 3
PERTZYE
Tier 3
SUCRAID
Tier 3
ULTRESA
Tier 3
ST; N1
VIOKACE
Tier 3
ST; N1
ZENPEP
Tier 2
ST; N1
*DIURETICS*
acetazolamide er
Tier 1
acetazolamide oral tablet 250 mg
Tier 1
ALDACTAZIDE
Tier 3
ALDACTONE
Tier 3
amiloride hcl oral
Tier 1
amiloride-hydrochlorothiazide
Tier 1
LGC
bumetanide oral tablet 0.5 mg, 1 mg
Tier 1
LGC
bumetanide oral tablet 2 mg
Tier 1
chlorothiazide oral tablet 500 mg
Tier 1
chlorthalidone oral tablet 25 mg, 50 mg
Tier 1
DEMADEX
Tier 3
DIAMOX SEQUELS
Tier 3
DIURIL
Tier 3
DYAZIDE
Tier 3
DYRENIUM
Tier 3
EDECRIN
Tier 3
furosemide oral solution 10 mg/ml, 40 mg/4ml
Tier 1
furosemide oral tablet
Tier 1
LGC
hydrochlorothiazide oral capsule
Tier 1
LGC
hydrochlorothiazide oral tablet 12.5 mg
Tier 1
LGC
(Updated 07/01/15)
75
Drug Name
Drug Status
Drug Details
hydrochlorothiazide oral tablet 25 mg, 50 mg
Tier 1
LGC
indapamide oral
Tier 1
INTROL
Tier 3
LASIX
Tier 3
MAXZIDE
Tier 3
MAXZIDE-25
Tier 3
methazolamide oral
Tier 1
metolazone
Tier 1
MICROZIDE
Tier 3
NEPTAZANE
Tier 3
spironolactone oral tablet 100 mg, 50 mg
Tier 1
spironolactone oral tablet 25 mg
Tier 1
spironolactone-hctz
Tier 1
torsemide oral
Tier 1
triamterene-hctz oral capsule 37.5-25 mg
Tier 1
LGC
triamterene-hctz oral tablet
Tier 1
LGC
ZAROXOLYN
Tier 3
LGC
*ENDOCRINE AND METABOLIC AGENTS MISC.*
ACTHAR HP
Tier 2
PA
ACTONEL ORAL TABLET 150 MG, 30 MG, 35
MG, 5 MG
Tier 3
ST; #; QL
ALDURAZYME
Tier 2
PA
alendronate sodium oral tablet 10 mg, 35 mg, 40 mg,
5 mg
Tier 1
QL
alendronate sodium oral tablet 70 mg
Tier 1
LGC; QL
AMMONUL
Tier 3
ATELVIA
Tier 3
ST; QL
BINOSTO
Tier 3
ST; N1; QL
BONIVA ORAL
Tier 3
N1; QL
BUPHENYL
Tier 2
cabergoline
Tier 1
calcitonin (salmon)
Tier 1
calcitriol oral
Tier 1
CARBAGLU
Tier 3
CARNITOR ORAL
Tier 3
CARNITOR SF
Tier 3
CLOMID
Tier 3
clomiphene citrate oral
Tier 1
QL
(Updated 07/01/15)
76
Drug Name
Drug Status
Drug Details
CYSTADANE
Tier 2
DDAVP NASAL
Tier 3
PA
DDAVP ORAL
Tier 3
ST; N1
desmopressin ace rhinal tube
Tier 1
PA
desmopressin ace spray refrig
Tier 1
PA
desmopressin acetate oral
Tier 1
desmopressin acetate spray
Tier 1
PA
ELAPRASE
Tier 2
PA
etidronate disodium
Tier 3
EVISTA
Tier 3
FABRAZYME
Tier 2
PA
FORTEO
Tier 3
PA
FOSAMAX ORAL TABLET 70 MG
Tier 3
QL
FOSAMAX PLUS D
Tier 3
ST; N1; QL
GANITE
Tier 3
GENOTROPIN
Tier 3
PA
GENOTROPIN MINIQUICK
Tier 3
PA
HUMATROPE
Tier 3
PA
ibandronate sodium oral
Tier 3
QL
INCRELEX
Tier 2
PA
KUVAN ORAL PACKET 100 MG
Tier 2
KUVAN ORAL TABLET SOLUBLE
Tier 2
levocarnitine oral solution
Tier 1
levocarnitine oral tablet
Tier 1
LUPANETA PACK
Tier 3
LUPRON DEPOT-PED
Tier 2
MIACALCIN INJECTION
Tier 3
MIACALCIN NASAL
Tier 3
QL
MINIRIN
Tier 1
PA
NAGLAZYME
Tier 2
PA
NATPARA
Tier 3
PA; QL
NORDITROPIN FLEXPRO
SUBCUTANEOUS* SOLUTION 15 MG/1.5ML
Tier 3
PA
NORDITROPIN NORDIFLEX PEN
Tier 3
PA
NUTROPIN AQ
Tier 3
PA
NUTROPIN AQ NUSPIN 10
Tier 3
PA
Tier 3
PA
Tier 3
PA
PA
NUTROPIN AQ PEN
Tier 3
PA
(Updated 07/01/15)
77
Drug Name
Drug Status
Drug Details
octreotide acetate
Tier 1
OMNITROPE SUBCUTANEOUS* SOLUTION
RECONSTITUTED
Tier 2
ORFADIN
Tier 2
pamidronate disodium intravenous* solution 30
mg/10ml, 90 mg/10ml
Tier 1
PA
pamidronate disodium intravenous* solution
reconstituted
Tier 1
PA
paricalcitol
Tier 1
PROLIA
Tier 3
raloxifene hcl
PA
PA
CE
RAVICTI
Tier 3
PA
RECLAST
Tier 3
PA; QL
risedronate sodium oral tablet 30 mg, 35 mg, 5 mg
Tier 3
ROCALTROL
Tier 3
SAIZEN
Tier 3
PA
SAIZEN CLICK.EASY
Tier 3
PA
SAMSCA
Tier 2
PA
SANDOSTATIN
Tier 3
SANDOSTATIN LAR DEPOT
Tier 3
SENSIPAR
Tier 3
SEROPHENE
Tier 1
SEROSTIM
Tier 3
PA
SIGNIFOR
Tier 3
PA; QL
SIGNIFOR LAR
Tier 3
PA; QL
SKELID
Tier 3
QL
sodium phenylbutyrate oral
Tier 1
SOMATULINE DEPOT
Tier 3
SOMAVERT
Tier 3
PA
STIMATE
Tier 3
PA
SUPPRELIN LA
Tier 2
SYNAREL
Tier 3
TEV-TROPIN
Tier 3
VIMIZIM
Tier 2
XGEVA
Tier 3
ZEMPLAR
Tier 2
zoledronic acid intravenous* concentrate
Tier 1
PA; QL
zoledronic acid intravenous* solution 5 mg/100ml
Tier 1
PA; QL
PA
PA
(Updated 07/01/15)
78
Drug Name
Drug Status
Drug Details
ZOMACTON SUBCUTANEOUS* SOLUTION
RECONSTITUTED 5 MG
Tier 3
PA
ZOMETA INTRAVENOUS* CONCENTRATE
Tier 3
PA; QL
ZOMETA INTRAVENOUS* SOLUTION
Tier 3
QL
ZORBTIVE
Tier 3
PA
ACTIVELLA
Tier 3
QL
ALORA TRANSDERMAL PATCH BIWEEKLY
0.025 MG/24HR, 0.05 MG/24HR, 0.075
MG/24HR, 0.1 MG/24HR
Tier 3
QL
ANGELIQ
Tier 3
QL
CENESTIN
Tier 3
QL
CLIMARA
Tier 3
QL
CLIMARA PRO
Tier 3
#; QL
COMBIPATCH
Tier 3
#; QL
COVARYX
Tier 1
COVARYX HS
Tier 1
DIVIGEL
Tier 3
DUAVEE
Tier 2
EEMT
Tier 1
EEMT HS
Tier 1
ELESTRIN
Tier 3
QL
ENJUVIA
Tier 3
QL
est estrogens-methyltest
Tier 1
est estrogens-methyltest ds
Tier 1
est estrogens-methyltest hs
Tier 1
ESTRACE ORAL
Tier 3
ESTRADERM
Tier 3
QL
estradiol oral
Tier 1
LGC
estradiol transdermal patch weekly
Tier 1
QL
estradiol-norethindrone acet
Tier 1
ESTRASORB
Tier 3
#; QL
ESTROGEL
Tier 3
QL
estropipate oral tablet 0.75 mg, 1.5 mg
Tier 1
LGC
EVAMIST
Tier 3
QL
FEMHRT 1/5
Tier 3
QL
FEMHRT LOW DOSE
Tier 3
QL
JEVANTIQUE
Tier 1
MENEST
Tier 3
*ESTROGENS*
QL
(Updated 07/01/15)
79
Drug Name
Drug Status
Drug Details
MENOSTAR
Tier 3
QL
methyltest-est estrogens
Tier 1
methyltest-est estrogens hs
Tier 1
MIMVEY
Tier 1
QL
MINIVELLE
Tier 3
QL
norethindrone-eth estradiol oral tablet 0.5-2.5
mg-mcg
Tier 1
QL
ORTHO-EST 0.625
Tier 1
ORTHO-EST 1.25
Tier 1
PREFEST
Tier 3
PREMARIN ORAL
Tier 2
PREMPHASE
Tier 2
PREMPRO
Tier 2
VIVELLE-DOT TRANSDERMAL PATCH
BIWEEKLY 0.025 MG/24HR, 0.0375 MG/24HR,
0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR
Tier 3
QL
CIPRO ORAL SUSPENSION
RECONSTITUTED
Tier 3
PA
CIPRO ORAL TABLET 250 MG, 500 MG
Tier 3
PA
CIPRO XR
Tier 3
PA
ciprofloxacin hcl oral
Tier 1
PA
ciprofloxacin-ciproflox hcl er
Tier 1
PA
FACTIVE
Tier 3
PA; #
LEVAQUIN ORAL
Tier 3
PA
levofloxacin oral
Tier 1
PA
NOROXIN
Tier 3
PA
ofloxacin oral
Tier 1
PA
QL
*FLUOROQUINOLONES*
*GASTROINTESTINAL AGENTS - MISC.*
ACTIGALL
Tier 3
AMITIZA
Tier 2
ST; N1; QL
APRISO
Tier 3
ST; N1; QL
ASACOL HD
Tier 2
#; QL
AURYXIA
Tier 3
AZULFIDINE
Tier 3
ST; N1; QL
AZULFIDINE EN-TABS
Tier 3
ST; N1; QL
balsalazide disodium
Tier 1
QL
calcium acetate (phos binder)
Tier 1
calcium acetate oral capsule
Tier 1
(Updated 07/01/15)
80
Drug Name
Drug Status
Drug Details
CANASA
Tier 2
CHENODAL
Tier 3
CHOLBAM
Tier 3
PA
COLAZAL
Tier 3
ST; N1; QL
cromolyn sodium oral
Tier 1
DELZICOL
Tier 2
QL
DIPENTUM
Tier 3
ST; N1; QL
ELIPHOS
Tier 3
enulose
Tier 1
FOSRENOL
Tier 2
GASTROCROM
Tier 3
GATTEX
Tier 3
generlac
Tier 1
GIAZO
Tier 3
lactulose encephalopathy
Tier 1
LIALDA
Tier 2
QL
LINZESS
Tier 3
ST; N1; QL
LOTRONEX
Tier 3
PA
mesalamine enema
Tier 1
metoclopramide hcl oral solution 1 mg/ml, 10
mg/10ml
Tier 1
metoclopramide hcl oral solution 5 mg/5ml
Tier 1
LGC
metoclopramide hcl oral tablet 10 mg
Tier 1
LGC
metoclopramide hcl oral tablet 5 mg
Tier 1
metoclopramide hcl oral tablet dispersible
Tier 1
METOZOLV ODT ORAL TABLET
DISPERSIBLE 5 MG
Tier 3
MOVANTIK
Tier 3
PA; QL
PENTASA ORAL CAPSULE EXTENDED
RELEASE* 250 MG, 500 MG
Tier 2
QL
PHOSLO
Tier 3
ST; N1
PHOSLYRA
Tier 2
REGLAN ORAL
Tier 3
RELISTOR SUBCUTANEOUS* KIT
Tier 2
PA; QL
RELISTOR SUBCUTANEOUS* SOLUTION 12
MG/0.6ML, 8 MG/0.4ML
Tier 2
PA; QL
REMICADE
Tier 2
RENAGEL
Tier 3
RENVELA
Tier 2
QL
LGC
PA
PA; ST; N1; QL
ST; N1; #
(Updated 07/01/15)
81
Drug Name
Drug Status
Drug Details
SFROWASA
Tier 3
sulfasalazine oral
Tier 1
QL
SULFAZINE
Tier 1
QL
SULFAZINE EC
Tier 1
QL
URSO 250
Tier 3
URSO FORTE
Tier 3
ursodiol oral
Tier 1
VELPHORO
Tier 3
*GENERAL ANESTHETICS*
FORANE
Tier 3
isoflurane
Tier 1
sevoflurane
Tier 1
SOJOURN
Tier 1
SUPRANE
Tier 3
TERRELL
Tier 1
ULTANE
Tier 3
*GENITOURINARY AGENTS MISCELLANEOUS*
acetic acid irrigation
Tier 1
alfuzosin hcl er
Tier 1
aminoacetic acid
Tier 1
ARGYLE STERILE SALINE
Tier 1
AVODART
Tier 2
CARDURA XL
Tier 3
citric acid-sodium citrate
Tier 1
CITROLITH
Tier 3
CURITY STERILE SALINE
Tier 1
CYSTAGON
Tier 3
cytra k crystals
Tier 1
cytra-2
Tier 1
CYTRA-3
Tier 3
cytra-k
Tier 3
ELMIRON
Tier 2
PA; QL
finasteride oral tablet 5 mg
Tier 1
PA
FLOMAX
Tier 3
PA; ST; N1
glycine irrigation
Tier 1
glycine urologic
Tier 1
JALYN
Tier 2
PA
PA; #
PA; #
K-PHOS NO 2
Tier 3
(Updated 07/01/15)
82
Drug Name
Drug Status
Drug Details
LITHOSTAT
Tier 3
neomycin-polymyxin b gu
Tier 1
NEOSPORIN GU IRRIGANT
Tier 3
ORACIT
Tier 3
PHENAZO ORAL TABLET 200 MG
Tier 1
phenazopyridine hcl oral tablet 100 mg
Tier 1
phenazopyridine hcl oral tablet 200 mg
Tier 1
potassium citrate-citric acid oral packet
Tier 1
potassium citrate-citric acid oral solution
Tier 3
PROCYSBI ORAL CAPSULE DELAYED
RELEASE 25 MG, 75 MG
Tier 3
PA; ST; N1; QL
PROSCAR
Tier 3
PA
RAPAFLO
Tier 2
PA
RENACIDIN
Tier 3
RESECTISOL
Tier 3
sodium chloride irrigation
Tier 1
tamsulosin hcl
Tier 1
TARON-CRYSTALS
Tier 1
THIOLA
Tier 3
UROCIT-K 10
Tier 3
UROCIT-K 5
Tier 3
UROXATRAL
Tier 3
PA; ST; N1
allopurinol oral
Tier 1
LGC
colchicine oral tablet
Tier 1
colchicine-probenecid
Tier 1
COLCRYS
Tier 3
QL
KRYSTEXXA
Tier 3
PA
MITIGARE
Tier 3
PA; ST; QL
probenecid oral
Tier 1
ULORIC
Tier 3
ZYLOPRIM
Tier 3
LGC
PA; LGC
*GOUT AGENTS*
ST; N1; QL
*HEMATOLOGICAL AGENTS - MISC.*
ADVATE
Tier 2
PA
AGGRENOX
Tier 2
#
AGRYLIN
Tier 3
ALPHANATE/VWF COMPLEX/HUMAN
Tier 3
PA
ALPHANINE SD INTRAVENOUS*
SOLUTION RECONSTITUTED 1500 UNIT
Tier 3
PA
(Updated 07/01/15)
83
Drug Name
Drug Status
Drug Details
anagrelide hcl
Tier 1
BEBULIN
Tier 3
PA
BEBULIN VH
Tier 3
PA
BENEFIX
Tier 3
PA
BERINERT
Tier 3
PA
BRILINTA
Tier 2
QL
cilostazol
Tier 1
CINRYZE
Tier 2
clopidogrel bisulfate oral tablet 300 mg
Tier 1
clopidogrel bisulfate oral tablet 75 mg
Tier 1
QL
CORIFACT
Tier 3
PA
dipyridamole oral
Tier 1
EFFIENT
Tier 3
PA; QL
FEIBA NF
Tier 2
PA
FEIBA VH IMMUNO
Tier 2
PA
FIRAZYR
Tier 2
PA
HELIXATE FS
Tier 3
PA
HEMOFIL M
Tier 3
PA
HUMATE-P
Tier 3
PA
KALBITOR
Tier 3
PA
KCENTRA INTRAVENOUS* KIT 500 UNIT
Tier 3
PA
KOATE-DVI
Tier 3
PA
KOGENATE FS
Tier 3
PA
KOGENATE FS BIO-SET
Tier 3
PA
MONOCLATE-P
Tier 2
PA
MONONINE INTRAVENOUS* SOLUTION
RECONSTITUTED 250 UNIT
Tier 2
PA
NOVOEIGHT INTRAVENOUS* SOLUTION
RECONSTITUTED 1500 UNIT, 2000 UNIT,
3000 UNIT
Tier 3
PA
NOVOSEVEN RT
Tier 2
PA
pentoxifylline er
Tier 1
PERSANTINE
Tier 3
PLAVIX ORAL TABLET 300 MG
Tier 3
N1
PLAVIX ORAL TABLET 75 MG
Tier 3
N1; QL
PLETAL
Tier 3
PROFILNINE SD
Tier 3
PA
RECOMBINATE
Tier 3
PA
RIASTAP
Tier 2
PA
PA
(Updated 07/01/15)
84
Drug Name
Drug Status
Drug Details
rixubis
Tier 3
PA
RUCONEST
Tier 3
PA
SOLIRIS
Tier 2
PA
ticlopidine hcl
Tier 1
TRETTEN
Tier 3
PA
WILATE INTRAVENOUS* SOLUTION
RECONSTITUTED 1000-1000 UNIT, 500-500
UNIT
Tier 3
PA
XYNTHA
Tier 3
PA
XYNTHA SOLOFUSE
Tier 3
PA
*HEMATOPOIETIC AGENTS*
active fe
Tier 3
AIRAVITE
Tier 1
ALBAFORT INTRAMUSCULAR* SOLUTION
Tier 3
ANIMI-3
Tier 3
ANIMI-3/VITAMIN D
Tier 3
ARANESP (ALBUMIN FREE)
Tier 2
BIFERARX
Tier 3
bp vit 3
Tier 3
CENFOL
Tier 3
CENTRATEX
Tier 3
CERDELGA
Tier 3
PA; QL
CEREZYME
Tier 2
PA
CORVITA 150
Tier 1
DIVISTA
Tier 3
DROXIA
Tier 3
ED CYTE F
Tier 3
ELELYSO
Tier 3
fabb
Tier 1
fa-cyanocobalamin-pyridoxine
Tier 1
fa-vitamin b-6-vitamin b-12
Tier 1
fe 90 plus
Tier 3
FER-IN-SOL
CE
fer-iron
CE
FERIVA
Tier 3
FERIVAFA
Tier 3
ferocon
Tier 1
ferotrinsic
Tier 1
FERRALET 90
Tier 3
PA
PA
(Updated 07/01/15)
85
Drug Name
Drug Status
ferraplus 90
Tier 3
ferrex 150 forte
Tier 1
FERREX 150 FORTE PLUS
Tier 3
FERREX 28
Tier 3
FERRLECIT
Tier 3
FERROCITE PLUS
Tier 1
FERROGELS FORTE
Tier 1
FERRO-PLEX HEMATINIC
Tier 3
FERROTRIN
Tier 3
ferrous sulfate oral solution
Drug Details
CE
folbee
Tier 1
FOLCAPS
Tier 1
folic acid oral tablet 1 mg
CE
folic acid oral tablet 400 mcg, 800 mcg
CE
FOLIVANE-F
Tier 3
FOLIVANE-PLUS
Tier 3
folplex 2.2
Tier 1
foltrin
Tier 1
FUSION PLUS
Tier 3
GRANIX
Tier 3
hematinic plus complex
Tier 1
hematinic plus vit/minerals
Tier 1
hematinic/folic acid
Tier 1
HEMATOGEN FA
Tier 3
HEMATOGEN FORTE
Tier 1
hemetab
Tier 3
HEMOCYTE PLUS
Tier 3
HEMOCYTE-F ORAL TABLET
Tier 1
hemocyte-plus
Tier 1
IFEREX 150 FORTE
Tier 1
INTEGRA F
Tier 3
INTEGRA PLUS
Tier 3
IROSPAN 24/6
Tier 3
LEUKINE INTRAVENOUS*
Tier 3
martinic
Tier 1
MAXARON FORTE
Tier 3
MIRCERA
Tier 3
MULTIGEN
Tier 3
LGC
PA
(Updated 07/01/15)
86
Drug Name
Drug Status
Drug Details
MULTIGEN FOLIC
Tier 3
MULTIGEN PLUS
Tier 3
myferon 150 forte
Tier 1
na ferric gluc cplx in sucrose
Tier 1
NASCOBAL
Tier 3
NATALVIRT FLT
Tier 3
NEPHRON FA
Tier 3
NEULASTA
Tier 2
NEUMEGA
Tier 3
NEUPOGEN
Tier 3
neurin-sl
Tier 3
NOVAFERRUM
Tier 3
NPLATE
Tier 3
NUFOL
Tier 1
NULECIT
Tier 2
OMONTYS
Tier 3
poly-iron 150 forte
Tier 1
polysaccharide iron forte
Tier 1
PRE-FOLIC
Tier 3
PROCRIT INJECTION SOLUTION 40000
UNIT/ML
Tier 2
PROFERRIN-FORTE
Tier 3
PROMACTA
Tier 3
PROTECTIRON
Tier 3
purefe plus
Tier 3
purevit dualfe plus
Tier 1
revesta
Tier 3
se-tan plus
Tier 1
TANDEM F
Tier 3
taron forte
Tier 3
tl gard rx
Tier 1
tl icon
Tier 1
TRICON
Tier 1
trigels-f forte
Tier 1
VENOFER
Tier 3
virt-vite
Tier 1
VPRIV
Tier 2
PA
ZAVESCA
Tier 3
PA; #
PA
PA
PA
(Updated 07/01/15)
87
Drug Name
Drug Status
Drug Details
*HEMOSTATICS*
AMICAR
Tier 3
aminocaproic acid oral syrup
Tier 1
aminocaproic acid oral tablet 500 mg
Tier 1
ARTISS
Tier 3
EVICEL
Tier 3
LYSTEDA
Tier 3
monsels ferric subsulfate
Tier 3
TISSEEL VH
Tier 3
TISSEEL VHSD
Tier 3
tranexamic acid oral
Tier 1
QL
AMBIEN CR
Tier 3
ST; N1; QL
AMBIEN ORAL TABLET 10 MG, 5 MG
Tier 3
ST; N1; QL
BELSOMRA
Tier 3
ST; QL
BUTISOL SODIUM
Tier 3
DORAL
Tier 3
EDLUAR
Tier 3
estazolam
Tier 1
eszopiclone
Tier 3
flurazepam hcl
Tier 1
HALCION
Tier 3
HETLIOZ
Tier 3
INTERMEZZO SUBLINGUAL TABLET
SUBLINGUAL 1.75 MG
Tier 3
ST; N1; QL
INTERMEZZO SUBLINGUAL TABLET
SUBLINGUAL 3.5 MG
Tier 3
PA; ST; N1; QL
LUNESTA
Tier 3
PA; ST; N1; QL
midazolam hcl oral
Tier 1
phenobarbital oral elixir
Tier 1
phenobarbital oral solution
Tier 1
phenobarbital oral tablet 16.2 mg, 32.4 mg
Tier 1
RESTORIL
Tier 3
ROZEREM
Tier 3
SECONAL
Tier 3
SILENOR
Tier 3
ST; N1; QL
SONATA ORAL CAPSULE 10 MG, 5 MG
Tier 3
ST; N1; QL
temazepam
Tier 1
ST; N1; QL
*HYPNOTICS/SEDATIVES/SLEEP
DISORDER AGENTS*
ST; N1; QL
PA; ST; N1; QL
ST; N1; QL
(Updated 07/01/15)
88
Drug Name
Drug Status
Drug Details
triazolam
Tier 1
zaleplon oral capsule 10 mg, 5 mg
Tier 1
QL
zolpidem tartrate er
Tier 1
QL
zolpidem tartrate oral tablet 10 mg, 5 mg
Tier 1
QL
ZOLPIMIST
Tier 3
ST; N1; QL
CLEARLAX ORAL POWDER
Tier 1
LGC
COLYTE WITH FLAVOR PACKS ORAL
SOLUTION RECONSTITUTED 227.1 GM
Tier 3
constulose
Tier 1
*LAXATIVES*
gavilax oral packet
CE
GAVILYTE-C
Tier 1
GAVILYTE-G
Tier 1
GAVILYTE-H
Tier 1
GAVILYTE-N WITH FLAVOR PACK
Tier 1
GOLYTELY
Tier 3
KRISTALOSE
Tier 3
lactulose oral solution 10 gm/15ml
Tier 1
lactulose oral solution 20 gm/30ml
Tier 1
MOVIPREP
Tier 2
NULYTELY WITH FLAVOR PACKS
Tier 3
OSMOPREP
Tier 3
peg 3350/electrolytes
Tier 1
peg 3350-kcl-na bicarb-nacl
Tier 1
peg-3350/electrolytes
Tier 1
PEG-PREP
Tier 1
PREPOPIK
Tier 3
SUCLEAR
Tier 3
SUPREP BOWEL PREP
Tier 3
TRILYTE
Tier 1
LGC
*MACROLIDES*
azithromycin oral suspension reconstituted
Tier 1
azithromycin oral tablet
Tier 1
BIAXIN
Tier 3
BIAXIN XL
Tier 3
BIAXIN XL PAC
Tier 3
clarithromycin er
Tier 1
clarithromycin oral
Tier 1
DIFICID
Tier 3
QL
(Updated 07/01/15)
89
Drug Name
Drug Status
E.E.S. 400
Tier 3
E.E.S. GRANULES
Tier 3
ERYPED 200
Tier 3
ERYPED 400
Tier 3
ERY-TAB
Tier 3
ERYTHROCIN STEARATE
Tier 3
erythromycin base oral capsule delayed release
particles
Tier 1
PCE
Tier 3
ZITHROMAX ORAL
Tier 3
ZITHROMAX TRI-PAK
Tier 3
ZITHROMAX Z-PAK
Tier 3
ZMAX
Tier 3
Drug Details
*MEDICAL DEVICES*
1st choice lancets super thin
Tier 1
1st choice lancets thin
Tier 1
1st choice lancets ultra thin
Tier 1
1st choice pen needles
Tier 3
1st tier unifine pentips
Tier 3
1st tier unifine pentips plus
Tier 3
1st tier unilet comfortouch
Tier 3
ACCU-CHEK ACTIVE GLUCOSE CONT
Tier 3
ACCU-CHEK AVIVA IN VITRO SOLUTION
Tier 3
ACCU-CHEK COMFORT CURVE IN VITRO
SOLUTION
Tier 3
ACCU-CHEK COMFORT CURVE LINEAR
Tier 3
ACCU-CHEK COMPACT BLUE CONTROL
Tier 3
ACCU-CHEK COMPACT PLUS CONTROL
Tier 3
ACCU-CHEK FASTCLIX LANCET
Tier 3
ACCU-CHEK FASTCLIX LANCETS
Tier 3
ACCU-CHEK INSTANT CONTROL
Tier 3
ACCU-CHEK MULTICLIX LANCET DEV
Tier 3
ACCU-CHEK MULTICLIX LANCETS
Tier 3
ACCU-CHEK SAFE-T PRO LANCETS
Tier 3
ACCU-CHEK SMARTVIEW CONTROL
Tier 3
ACCU-CHEK SOFT TOUCH LANCETS
Tier 3
ACCU-CHEK SOFTCLIX LANCET DEV
Tier 3
ACCU-CHEK SOFTCLIX LANCETS
Tier 3
ACCUTREND GLUCOSE CONTROL
Tier 3
(Updated 07/01/15)
90
Drug Name
Drug Status
ACE AEROSOL CLOUD ENHANCER
Tier 3
acti-lance 28g
Tier 3
acti-lance lite lancets 28g
Tier 1
acti-lance special lancets 17g
Tier 1
acti-lance universal 23g
Tier 3
ACTIVITY POUCH
Tier 3
ACURA CONTROL
Tier 3
ADAPTER PED DISPOSABLE
Tier 3
adjustable lancing device
Tier 3
adult aerosol mask
Tier 3
adult mask
Tier 3
adult mask large
Tier 3
ADVANCE INTUITION CONTROL
Tier 3
ADVANCE MICRO-DRAW CONTROL
Tier 3
ADVANCE MICRO-DRAW NORMAL
Tier 3
ADVOCATE CONTROL SOLUTION
Tier 3
ADVOCATE INSULIN PEN NEEDLES 31G X 5
MM , 31G X 8 MM
Tier 3
ADVOCATE INSULIN SYRINGE
Tier 3
ADVOCATE LANCETS
Tier 3
ADVOCATE LANCING DEVICE
Tier 3
ADVOCATE RAPID-SAFE LANCING
Tier 3
ADVOCATE REDI-CODE+ CONTROL
Tier 3
ADVOCATE SAFETY LANCETS
Tier 3
AEROCHAMBER MINI CHAMBER
Tier 3
AEROCHAMBER MV
Tier 3
AEROCHAMBER PLUS
Tier 3
AEROCHAMBER PLUS FLO-VU
Tier 3
AEROCHAMBER PLUS FLO-VU LARGE
Tier 3
AEROCHAMBER PLUS FLO-VU MEDIUM
Tier 3
AEROCHAMBER PLUS FLO-VU SMALL
Tier 3
AEROCHAMBER PLUS FLO-VU W/MASK
Tier 3
AEROCHAMBER PLUS FLOW VU
Tier 3
AEROCHAMBER PLUS W/MASK
Tier 3
AEROCHAMBER PLUS W/MASK SMALL
Tier 3
AEROCHAMBER W/FLOWSIGNAL
Tier 3
AEROCHAMBER Z-STAT PLUS
Tier 3
AEROCHAMBER Z-STAT PLUS CHAMBR
Tier 3
Drug Details
AEROCHAMBER Z-STAT PLUS/LARGE
Tier 3
(Updated 07/01/15)
91
Drug Name
Drug Status
AEROCHAMBER Z-STAT PLUS/MEDIUM
Tier 3
AEROCHAMBER Z-STAT PLUS/SMALL
Tier 3
AEROTRACH PLUS
Tier 3
af lancets super thin
Tier 1
AGAMATRIX CONTROL
Tier 3
AGAMATRIX ULTRA-THIN LANCETS
Tier 3
AIRS PEDIATRIC AEROSOL MASK
Tier 3
AIRZONE PEAK FLOW METER
Tier 3
ALCOH-GLOVE CONTOURED WIPE
Tier 3
alcohol pads
Tier 3
alcohol prep
Tier 3
alcohol prep pad
Tier 3
alcohol preps
Tier 3
alcohol swabs
Tier 3
alcohol wipes
Tier 3
ALL FLOW 1000 PFT FILTER
Tier 3
alternate site lancing device
Tier 3
aqua lance adjustable lancing
Tier 3
ARIAL CHAMBER
Tier 3
ASCENSIA AUTODISC CONTROL
Tier 3
ASCENSIA AUTODISC CONTROLS
Tier 3
ASSESS FULL RANGE PEAK METER
Tier 3
ASSESS LOW RANGE PEAK METER
Tier 3
ASSESS PEAK FLOW METER
Tier 3
ASSURE 3 CONTROL
Tier 3
ASSURE 4 CONTROL LEVEL 1 & 2
Tier 3
assure comfort lancets 28g
Tier 1
assure comfort lancets 30g
Tier 1
ASSURE DOSE CONTROL
Tier 3
ASSURE DOSE NORM/HIGH CONTROL
Tier 3
ASSURE HAEMOLANCE PLUS HIGH
Tier 3
ASSURE HAEMOLANCE PLUS LOW
Tier 3
ASSURE HAEMOLANCE PLUS MICRO
Tier 3
ASSURE HAEMOLANCE PLUS NORMAL
Tier 3
ASSURE HAEMOLANCE PLUS PED
Tier 3
ASSURE ID INSULIN SAFETY SYR
Tier 3
ASSURE II CONTROL
Tier 3
ASSURE II CONTROL LEVEL 1 & 2
Tier 3
Drug Details
(Updated 07/01/15)
92
Drug Name
Drug Status
ASSURE LANCE LANCETS
Tier 3
ASSURE LANCETS
Tier 3
ASSURE PRO CONTROL LEVEL 1 & 2
Tier 3
ASTHMA CHECK METER-ZONE SYSTEM
Tier 3
ASTHMAMENTOR
Tier 3
AT LAST CONTROL
Tier 3
AT LAST LANCETS
Tier 3
AURORA HEALTHCARE LANCETS
Tier 3
aurora lancet super thin 30g
Tier 3
aurora lancet thin 23g
Tier 3
aurora pen needles
Tier 3
aurora unifine pentips
Tier 3
AUTOJECT 2
Tier 3
AUTO-LANCET
Tier 3
AUTO-LANCET MINI
Tier 3
AUTOLET II CLINISAFE
Tier 3
AUTOLET IMPRESSION
Tier 3
AUTOLET LANCING DEVICE
Tier 3
AUTOLET LITE CLINISAFE
Tier 3
AUTOLET LITE STARTER PACK
Tier 3
AUTOLET MINI
Tier 3
AUTOLET PLATFORMS
Tier 3
BAYER BREEZE 2 CONTROL
Tier 3
BAYER CONTOUR
Tier 3
BAYER CONTOUR NEXT CONTROL
Tier 3
BAYER MICROLET 2 LANCING DEVIC
Tier 3
BAYER MICROLET LANCETS
Tier 3
BD AUTOSHIELD 29G X 12MM
Tier 3
BD AUTOSHIELD 29G X 5MM , 29G X 8MM
Tier 2
BD AUTOSHIELD DUO
Tier 2
BD INSULIN SYR ULTRAFINE II
Tier 3
BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X
5/8" 1 ML, 26G X 1/2" 1 ML, 27.5G X 5/8" 2 ML,
27G X 1/2" 1 ML, 29G X 1/2" 2 ML
Tier 2
BD INSULIN SYRINGE 28G X 1/2" 1 ML, 29G
X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 31G X 5/16" 0.3
ML, U-100 1 ML
Tier 3
BD INSULIN SYRINGE HALF-UNIT
Tier 3
Drug Details
BD INSULIN SYRINGE MICROFINE 27G X
Tier 2
5/8" 1 ML, 28G X 1/2" 0.3 ML
(Updated 07/01/15)
93
Drug Name
Drug Status
BD INSULIN SYRINGE MICROFINE 28G X
1/2" 0.5 ML, 28G X 1/2" 1 ML
Tier 3
BD INSULIN SYRINGE U-40
Tier 2
BD INSULIN SYRINGE ULTRAFINE 29G X
1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1
ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML,
31G X 5/16" 1 ML
Tier 3
BD INSULIN SYRINGE ULTRAFINE 30G X
1/2" 0.3 ML, 30G X 1/2" 1 ML, 31G X 15/64" 0.3
ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML
Tier 2
BD INTEGRA INSULIN SYRINGE
Tier 3
BD INTEGRA SYRINGE 25G X 1" 1 ML
Tier 2
BD LANCET DEVICE
Tier 3
BD LANCET ULTRAFINE 30G
Tier 3
Tier 3
BD MICROTAINER LANCETS
Tier 3
BD PEN NEEDLE MINI U/F
Tier 3
BD PEN NEEDLE NANO U/F
Tier 3
BD PEN NEEDLE SHORT U/F
Tier 3
BD PEN NEEDLE ULTRAFINE
Tier 3
BD SAFETYGLIDE INSULIN SYRINGE
Tier 3
BD SAFETY-LOK INSULIN SYRINGE
Tier 3
BD SWAB SINGLE USE REGULAR
Tier 3
BD SWABS SINGLE USE BUTTERFLY
Tier 3
BD ULTRA-FINE LANCETS
Tier 3
BREATHERITE
Tier 3
BREATHERITE COLL SPACER ADULT
Tier 3
BREATHERITE COLL SPACER CHILD
Tier 3
BREATHERITE COLL SPACER INFANT
Tier 3
BREATHERITE RIGID SPACER/MASK
Tier 3
BREATHERITE SPACER NEONATE
Tier 3
BREATHERITE SPACER SMALL CHILD
Tier 3
BREATHERITE/LARGE MASK
Tier 3
BREATHERITE/MEDIUM MASK
Tier 3
BREATHERITE/SMALL MASK
Tier 3
BUBBLES THE FISH II PEDI MASK
Tier 3
bullseye mini safety lancets
Tier 1
BULLSEYE SAFETY LANCETS
Tier 3
CARDIOCOM LANCING DEVICE
Tier 3
careone advanced lancing dev
Tier 3
Drug Details
(Updated 07/01/15)
94
Drug Name
Drug Status
careone lancet thin 23g
Tier 3
careone lancet ultra thin 28g
Tier 3
CAREONE ULTIGUARD INSULIN SYR
Tier 3
careone unifine pentips
Tier 3
careone unifine pentips plus
Tier 3
CARESENS CONTROL A
Tier 3
CLEANLET LANCETS 28G
Tier 3
CLEVER CHEK LANCETS
Tier 3
CLEVER CHOICE GLUCOSE CONTROL
Tier 3
clickfine pen needles
Tier 3
CLOSERCARE
Tier 3
co monitor replacement pieces
Tier 3
COAGUCHEK LANCETS
Tier 3
comfort assured lancets 28g
Tier 1
comfort assured lancets 33g
Tier 1
COMFORT EZ INSULIN SYRINGE 28G X 1/2"
0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML,
29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16"
0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML,
31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X
5/16" 1 ML
Tier 3
COMFORT EZ INSULIN SYRINGE 30G X 1/2"
0.3 ML, 30G X 1/2" 1 ML
Tier 2
COMFORT EZ PEN NEEDLES 31G X 5 MM ,
31G X 6 MM , 31G X 8 MM , 32G X 4 MM
Tier 3
comfort lancets
Tier 1
cone mask
Tier 3
control
Tier 3
CORNWALL METAL PIPETTING
Tier 3
CURITY ALCOHOL PREPS
Tier 3
CURITY ALCOHOL SWABS
Tier 3
cvs alcohol prep swabs
Tier 3
cvs alcohol swabs
Tier 3
cvs insulin syringe 30g x 1/2" 0.3 ml
Tier 2
cvs lancets 21g
Tier 1
cvs lancets micro thin 33g
Tier 1
cvs lancets original
Tier 1
cvs lancets thin
Tier 1
cvs lancets thin 26g
Tier 1
cvs lancets ultra thin 30g
Tier 1
Drug Details
(Updated 07/01/15)
95
Drug Name
Drug Status
cvs lancing device
Tier 3
cvs ultra thin lancets
Tier 1
DIASTAR EASY TEST II LANCETS
Tier 3
DIASTAR EASY TEST LANCETS
Tier 3
diatrue control level 1
Tier 3
Tier 3
Tier 3
DROPLET LANCETS ULTRA THIN 30G
Tier 3
DROPLET LANCING DEVICE
Tier 3
drug mart lancets thin 26g
Tier 1
drug mart lancets ultra thin
Tier 1
DRUG MART LANCING DEVICE
Tier 3
DRUG MART ON-THE-GO LANCET 30G
Tier 3
drug mart unifine pentips
Tier 3
DRUG MART UNILET LANCETS 28G
Tier 3
DRUG MART UNILET LANCETS 30G
Tier 3
duane reade lancet altern site
Tier 3
duane reade lancet super thin
Tier 3
duane reade lancet ultra thin
Tier 3
duane reade unifine pentips
Tier 3
DUO-CARE CONTROL SOLUTION
Tier 3
earloop mask
Tier 3
EASIVENT
Tier 3
EASIVENT MASK LARGE
Tier 3
EASIVENT MASK MEDIUM
Tier 3
EASIVENT MASK SMALL
Tier 3
easy comfort insulin syringe 30g x 1/2" 1 ml
Tier 2
easy comfort lancets
Tier 1
easy comfort pen needles 31g x 5 mm , 31g x 8 mm
Tier 3
easy mini lancing device
Tier 3
easy plus control
Tier 3
easy plus ii control
Tier 3
EASY STEP CONTROL
Tier 3
easy talk control
Tier 3
EASY TOUCH ALCOHOL PREP MEDIUM
Tier 3
EASY TOUCH CONTROL HIGH & LOW
Tier 3
EASY TOUCH INSULIN SAFETY SYR 29G X
1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.5
ML
Tier 3
Drug Details
(Updated 07/01/15)
96
Drug Name
Drug Status
EASY TOUCH INSULIN SAFETY SYR 30G X
1/2" 1 ML
Tier 2
EASY TOUCH INSULIN SYRINGE 27G X 1/2"
1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 1 ML
Tier 2
EASY TOUCH INSULIN SYRINGE 28G X 1/2"
0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML,
29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X
5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3
ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML
Tier 3
EASY TOUCH LANCETS 21G
Tier 3
Tier 3
Tier 3
Tier 3
EASY TOUCH LANCETS 28G/TWIST
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
EASY TOUCH LANCING DEVICE
Tier 3
EASY TOUCH PEN NEEDLES 29G X 12MM ,
31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G
X 5 MM , 32G X 6 MM
Tier 3
EASY TOUCH SAFETY LANCETS 21G
Tier 3
Tier 3
Tier 3
Tier 3
easy trak control
Tier 3
EASY TWIST & CAP LANCETS
Tier 3
EASYGLUCO CONTROL
Tier 3
EASYMAX 15 LEVEL 1 CONTROL
Tier 3
EASYMAX 15 LEVEL 2 CONTROL
Tier 3
EASYMAX CONTROL
Tier 3
EASYTEST II LANCETS
Tier 3
EASYTEST LANCETS
Tier 3
ECLIPSE CONTROL
Tier 3
EFLOW SCF AEROSOL HEAD
Tier 3
element compact control 2
Tier 3
element compact control 3
Tier 3
ELEMENT CONTROL
Tier 3
Drug Details
(Updated 07/01/15)
97
Drug Name
Drug Status
Drug Details
ELEMENT PLUS CONTROL
Tier 3
ELITE DC AUTO ADAPTER
Tier 3
elite-thin insulin syringe 28g x 5/16" 0.5 ml, 28g x
5/16" 1 ml, 29g x 5/16" 0.5 ml, 29g x 5/16" 1 ml
Tier 3
EMBRACE CONTROL
Tier 3
ENVISION CONTROL
Tier 3
eql color lancets 21g
Tier 1
eql color lancets micro 33g
Tier 1
eql short pen needle
Tier 3
eql super thin lancets 30g
Tier 1
eql thin lancets 26g
Tier 1
eql ultra short pen needle
Tier 3
EVENCARE CONTROL LOW/HIGH
Tier 3
EVENCARE G2 LOW/HIGH CONTROL
Tier 3
EVENCARE G3 LOW/HIGH CONTROL
Tier 3
EVOLUTION CONTROL
Tier 3
E-Z JECT LANCET MICRO-THIN 33G
Tier 3
E-Z JECT LANCET SUPER THIN 30G
Tier 3
E-Z JECT LANCETS
Tier 3
E-Z JECT LANCETS 21G
Tier 3
E-Z JECT LANCETS THIN 26G
Tier 3
EZ SMART BLOOD GLUCOSE LANCETS
Tier 3
E-Z SPACER
Tier 3
E-Z SPACER THE BODY GUARDS PK
Tier 3
EZ-LETS LANCETS 21G
Tier 3
EZ-LETS LANCETS 23G
Tier 3
EZ-LETS LANCETS 26G
Tier 3
EZ-LETS LANCETS 28G
Tier 3
EZ-LETS LANCETS 30G
Tier 3
FC FEMALE CONDOM
CE
FC2 FEMALE CONDOM
Tier 3
PA
CE
QL
FEMCAP
FIFTY50 ALCOHOL PREP
Tier 3
FIFTY50 CONTROL 2.0
Tier 3
FIFTY50 LANCING DEVICE
Tier 3
FIFTY50 PEN NEEDLES
Tier 3
FIFTY50 SAFETY SEAL LANCETS
Tier 3
FIFTY50 SUPERIOR COMFORT SYR
Tier 3
filter air pp
Tier 3
(Updated 07/01/15)
98
Drug Name
Drug Status
FINE 30
Tier 3
FINGERSTIX LANCETS
Tier 3
FORA CONTROL
Tier 3
FORA LANCETS
Tier 3
FORA LANCING DEVICE
Tier 3
FORACARE GDH CONTROL
Tier 3
freds pharmacy autolet lancing
Tier 3
freds pharmacy unifine pentip+
Tier 3
freds pharmacy unifine pentips
Tier 3
freds pharmacy unilet lanc 28g
Tier 3
freds pharmacy unilet lanc 30g
Tier 3
FREESTYLE CONTROL SOLUTION
Tier 3
FREESTYLE LANCETS
Tier 3
FREESTYLE PRECISION INS SYR
Tier 3
FREESTYLE UNISTICK II LANCETS
Tier 3
full kit nebulizer set
Tier 3
ge100 control
Tier 3
GENTLE-LET GP LANCETS
Tier 3
GENTLE-LET LANCETS
Tier 3
GENTLE-LET PLATFORMS
Tier 3
global alcohol prep ease
Tier 3
global ease inject pen needles
Tier 3
global inject ease insulin syr 30g x 1/2" 0.3 ml, 30g x
1/2" 1 ml
Tier 2
global inject ease lancets 28g
Tier 1
global inject ease lancets 30g
Tier 1
global lancing device
Tier 3
GLUCOCARD 01 CONTROL
Tier 3
GLUCOCARD EXPRESSION CONTROL
Tier 3
GLUCOCARD SHINE
Tier 3
GLUCOCARD SHINE CONTROL
Tier 3
GLUCOCARD X-SENSOR CONTROL
Tier 3
GLUCOCOM CONTROL
Tier 3
GLUCOCOM LANCETS 28G
Tier 3
Tier 3
Tier 3
GLUCOLAB CONTROL
Tier 3
GLUCOLET 2 AUTOMATIC LANCING
Tier 3
Drug Details
(Updated 07/01/15)
99
Drug Name
Drug Status
GLUCOPRO INSULIN SYRINGE 30G X 1/2"
0.3 ML, 30G X 1/2" 1 ML
Tier 2
GLUCOPRO INSULIN SYRINGE 30G X 5/16"
0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML,
31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X
5/16" 1 ML
Tier 3
glucose control
Tier 3
GLUCOSOURCE LANCET DEVICE
Tier 3
GLUCOSOURCE LANCETS
Tier 3
GMATE CONTROL LEVEL 2
Tier 3
gnp alcohol swabs
Tier 3
gnp clickfine pen needles
Tier 3
gnp lancets
Tier 1
gnp lancets 21g
Tier 1
gnp lancets micro thin 33g
Tier 1
gnp lancets super thin 30g
Tier 1
gnp lancets thin
Tier 1
gnp lancets thin 26g
Tier 1
gnp micro thin lancets 33g
Tier 1
gnp super thin lancets 30g
Tier 1
H&H THINLET LANCETS 26G
Tier 3
Tier 3
HAEMOLANCE
Tier 3
HAEMOLANCE LOW FLOW LANCETS
Tier 3
HAEMOLANCE PLUS
Tier 3
HAEMOLANCE PLUS HIGH FLOW
Tier 3
HAEMOLANCE PLUS LOW FLOW
Tier 3
HAEMOLANCE PLUS MAX FLOW
Tier 3
HAEMOLANCE PLUS PEDIATRIC FLOW
Tier 3
HEALTH CARE LANCING DEVICE
Tier 3
healthwise alcohol prep
Tier 3
healthwise lancets 30g
Tier 1
healthwise lancing pen
Tier 3
healthwise mini pen needles
Tier 3
healthwise pen needles
Tier 3
healthwise short pen needles
Tier 3
healthwise unifine pentips
Tier 3
healthy accents lancing device
Tier 3
healthy accents unifine pentip
Tier 3
Drug Details
(Updated 07/01/15)
100
Drug Name
Drug Status
healthy accents unilet lancets
Tier 1
HEALTHY LIVING FILTERS
Tier 3
HEALTHY LIVING MASKS
Tier 3
HEALTHY LIVING REPLACEMENT KIT
Tier 3
h-e-b incontrol adv lancing
Tier 3
h-e-b incontrol lancets 28g
Tier 1
h-e-b incontrol lancets 30g
Tier 1
h-e-b incontrol pen needles
Tier 3
hm lancets micro thin 33g
Tier 1
hm lancets ultra thin 30g
Tier 1
HUMATROPEN FOR 12MG
Tier 3
HUMATROPEN FOR 24MG
Tier 3
HUMATROPEN FOR 6MG
Tier 3
HYPOLANCE AST LANCING
Tier 3
HY-VEE LANCETS
Tier 3
hy-vee thin lancets
Tier 1
INFINITY CONTROL
Tier 3
inhaler companions
Tier 3
inject-ease
Tier 3
INJECT-EASE AUTOMATIC INJECTOR
Tier 3
INNOSPIRE REPLACEMENT FILTER
Tier 3
INSPIREASE
Tier 3
INSPIREASE BAGS
Tier 3
INSPIREASE MOUTHPIECE
Tier 3
INSPIREASE RESERVOIR BAGS
Tier 3
insupen pen needles 32g x 4 mm
Tier 3
INSUPEN SENSITIVE
Tier 3
INSUPEN ULTRAFIN
Tier 3
J-TIP KIT W/VIAL ADAPTERS
Tier 3
kinney lancets
Tier 1
kinney thin lancets
Tier 1
kmart valu insulin syringe 29g
Tier 3
kmart valu insulin syringe 30g
Tier 3
KOKO PEAK PRO MOUTHPIECE
Tier 3
kroger lancets
Tier 1
kroger lancets 21g
Tier 1
kroger lancets micro thin 33g
Tier 1
kroger lancets super thin
Tier 1
Drug Details
(Updated 07/01/15)
101
Drug Name
Drug Status
kroger lancets thin
Tier 1
kroger lancets thin 26g
Tier 1
kroger lancets ultrathin 30g
Tier 1
kroger lancing device
Tier 3
kroger pen needles
Tier 3
lady lite lancets
Tier 1
lancet device
Tier 3
lancets
Tier 1
lancets 28g
Tier 1
lancets 30g
Tier 1
lancets micro thin 33g
Tier 1
lancets super thin 28g
Tier 1
lancets thin
Tier 1
LANCETS ULTRA FINE
Tier 3
LANCETS ULTRA THIN
Tier 3
lancets ultra thin 30g
Tier 1
lancing device
Tier 3
leader advanced lancing device
Tier 3
LEADER UNIFINE PENTIPS
Tier 3
LEADER UNIFINE PENTIPS PLUS
Tier 3
LIBERTY GLUCOSE CONTROL
Tier 3
LIBERTY GLUCOSE CONTROL MID
Tier 3
LIBERTY MINI LANCING DEVICE
Tier 3
LIFESCAN UNISTIK 2
Tier 3
LIFESCAN UNISTIK II LANCETS
Tier 3
lite touch lancets
Tier 1
LITE TOUCH LANCING DEVICE
Tier 3
LITE TOUCH LANCING PEN
Tier 3
LITE TOUCH PEN NEEDLES
Tier 3
LITEAIRE
Tier 3
LITETOUCH INSULIN SYRINGE
Tier 3
LITETOUCH LANCETS
Tier 3
LITETOUCH MASK LARGE
Tier 3
LITETOUCH MASK MEDIUM
Tier 3
LITETOUCH MASK SMALL
Tier 3
LITETOUCH PEN NEEDLES
Tier 3
live better adv lancing device
Tier 3
live better lancet super thin
Tier 3
Drug Details
(Updated 07/01/15)
102
Drug Name
Drug Status
live better lancet ultra thin
Tier 3
live better pen needles
Tier 3
longs lancets standard
Tier 1
longs lancets thin
Tier 1
longs lancets ultra thin
Tier 1
MAGELLAN INSULIN SAFETY SYR
Tier 3
major comfort lancets
Tier 1
MASK VORTEX
Tier 3
MAXI-COMFORT INSULIN SYRINGE
Tier 3
MAXIMA CONTROL
Tier 3
medichoice safety lancet
Tier 3
medichoice safety lancet extra
Tier 3
medichoice safety lancet norm
Tier 3
medicine shoppe lancets
Tier 1
medicine shoppe lancets thin
Tier 1
medicine shoppe pen needles
Tier 3
medi-lance lancets
Tier 1
MEDISENSE GLUCOSE KETONE CONTR
Tier 3
MEDISENSE HI/MID/LOW CONTROL
Tier 3
MEDISENSE HIGH/LOW CONTROL
Tier 3
MEDISENSE MID CONTROL
Tier 3
MEDISENSE THIN LANCETS
Tier 3
MEDLANCE EXTRA 21G
Tier 3
MEDLANCE LITE 25G
Tier 3
MEDLANCE PLUS EXTRA 21G
Tier 3
MEDLANCE PLUS LANCETS
Tier 3
MEDLANCE PLUS LITE 25G
Tier 3
MEDLANCE PLUS SPECIAL 0.8MM
Tier 3
MEDLANCE PLUS SUPERLITE 30G
Tier 3
MEDLANCE PLUS UNIVERSAL 21G
Tier 3
MEDLANCE UNIVERSAL 21G
Tier 3
meijer alcohol swabs
Tier 3
MEIJER LANCETS
Tier 3
MEIJER LANCETS THIN
Tier 3
MEIJER LANCETS UNIVERSAL 21G
Tier 3
Tier 3
Tier 3
meijer pen needles
Tier 3
Drug Details
(Updated 07/01/15)
103
Drug Name
Drug Status
MEIJER SUPER THIN LANCETS
Tier 3
MICROCHAMBER
Tier 3
MICRODOT CONTROL
Tier 3
MICRODOT CONTROL HIGH/LOW
Tier 3
MICROELITE BATTERY
Tier 3
MICROELITE FILTER REPLACEMENTS
Tier 3
MICROLET LANCETS
Tier 3
MICROLIFE DIGITAL PEAK FLOW
Tier 3
MICROSPACER
Tier 3
MICROTAINER SAFETY FLOW LANCET
Tier 3
mini lancing device
Tier 3
MINI WRIGHT PEAK FLOW METER
Tier 3
MINIELITE FILTER REPLACEMENTS
Tier 3
MINIELITE RECHARGEABLE BATTERY
Tier 3
MONOJECT INSULIN SYRINGE 25G X 5/8" 1
ML, 27G X 1/2" 1 ML
Tier 2
MONOJECT INSULIN SYRINGE 28G X 1/2"
0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML,
29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16"
0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML,
31G X 5/16" 1 ML, U-100 1 ML
Tier 3
MONOJECT ULTRA COMFORT SYRINGE
Tier 3
MONOJECTOR END CAPS
Tier 3
MONOJECTOR OPD END CAPS
Tier 3
MONOLET LANCETS
Tier 3
MONOLET OPD LANCETS
Tier 3
MONOLETTOR SAFETY LANCETS
Tier 3
MOORE MONO INSULIN SYRINGE
Tier 3
multi-lancet device
Tier 3
MYGLUCOHEALTH CONTROL
Tier 3
MYGLUCOHEALTH LANCETS 30G
Tier 3
nebulizer air tube/plugs
Tier 3
nebulizer mask pediatric
Tier 3
NESSI SPACER WITH MASK LARGE
Tier 3
NESSI SPACER WITH MASK SM/MED
Tier 3
NESSI SPACER WITH MOUTHPIECE
Tier 3
NETGROUP LANCETS
Tier 3
NEUTEK 2TEK CONTROL
Tier 3
NEXGEN CONTROL
Tier 3
Drug Details
NORDIPEN 5 INJECTION DEVICE
Tier 3
(Updated 07/01/15)
104
Drug Name
Drug Status
NORDIPEN DELIVERY SYSTEM
Tier 3
nose clip
Tier 3
NOVA MAX PLUS GLU/KET CONTROL
Tier 3
NOVA SAFETY LANCETS 23G
Tier 3
Tier 3
NOVA SUREFLEX LANCETS
Tier 3
NOVA SUREFLEX LANCING DEVICE
Tier 3
NOVOFINE
Tier 3
NOVOFINE AUTOCOVER
Tier 3
NOVOTWIST
Tier 3
OMNIFLEX DIAPHRAGM
Tier 3
OMNITROPE PEN 10 INJ DEVICE
Tier 3
OMNITROPE PEN 5 INJ DEVICE
Tier 3
ON CALL EXPRESS GLUCOSE CONTR
Tier 3
ON CALL LANCETS
Tier 3
ON CALL LANCING DEVICE
Tier 3
ON CALL PLUS GLUCOSE CONTROL
Tier 3
ON CALL PLUS LANCETS
Tier 3
ON CALL PLUS LANCING DEVICE
Tier 3
ON CALL VIVID GLUCOSE CONTROL
Tier 3
ONE FLOW TESTER
Tier 3
ONETOUCH CLUB LANCETS FINE PT
Tier 3
ONETOUCH COMBO PACK
Tier 3
ONETOUCH DELICA LANCETS 33G
Tier 3
ONETOUCH DELICA LANCETS FINE
Tier 3
ONETOUCH DELICA LANCING DEV
Tier 3
ONETOUCH FINEPOINT LANCETS
Tier 3
ONETOUCH LANCETS
Tier 3
ONETOUCH SURESOFT LANCING DEV
Tier 3
ONETOUCH ULTRA CONTROL
Tier 3
ONETOUCH ULTRASOFT LANCETS
Tier 3
ONETOUCH VERIO IN VITRO SOLUTION
Tier 3
OPTICHAMBER ADVANTAGE
Tier 3
OPTICHAMBER ADVANTAGE-LG MASK
Tier 3
OPTICHAMBER ADVANTAGE-MED MASK
Tier 3
OPTICHAMBER ADVANTAGE-SM MASK
Tier 3
OPTICHAMBER DIAMOND
Tier 3
OPTICHAMBER DIAMOND-LG MASK
Tier 3
Drug Details
PA; QL
(Updated 07/01/15)
105
Drug Name
Drug Status
Drug Details
OPTICHAMBER DIAMOND-MD MASK
Tier 3
OPTICHAMBER DIAMOND-SM MASK
Tier 3
OPTICHAMBER FACE MASK-LARGE
Tier 3
OPTICHAMBER FACE MASK-MEDIUM
Tier 3
OPTICHAMBER FACE MASK-SMALL
Tier 3
OPTIHALER
Tier 3
OPTUMRX GLUCOSE CONTROL
Tier 3
ORSINI INSULIN SYRINGE
Tier 3
ORTHO DIAPHRAGM COIL
Tier 3
PA; QL
ORTHO DIAPHRAGM FLAT
Tier 3
PA; QL
PANDA MASK LARGE
Tier 3
PANDA MASK MEDIUM
Tier 3
PANDA MASK SMALL
Tier 3
PARI ALTERA NEBULIZER HANDSET
Tier 3
PARI BABY CONVERSION KIT
Tier 3
PARI ERAPID NEBULIZER HANDSET
Tier 3
PARI EXPIRATORY FILTER SET
Tier 3
PARI MASK SET
Tier 3
PARI SOFT PLASTIC ADULT MASK
Tier 3
PARI SOFT PLASTIC PED MASK
Tier 3
pc lancets super thin 30g
Tier 1
pc unifine pentips
Tier 3
pca injector
Tier 3
PEAK AIR PEAK FLOW METER
Tier 3
pediatric aerosol mask
Tier 3
pediatric mouthpiece
Tier 3
PEDIATRIC PANDA MASK
Tier 3
pen needles
Tier 3
pen needles 1/2"
Tier 3
pen needles 3/16"
Tier 3
pen needles 5/16"
Tier 3
PENLET II BLOOD SAMPLER
Tier 3
PENLET II REPLACEMENT CAP
Tier 3
PERFECT LANCETS 28G
Tier 3
PERFECT LANCETS 30G
Tier 3
PERSONAL BEST FULL RANGE
Tier 3
PERSONAL BEST LOW RANGE
Tier 3
PFLEX
Tier 3
(Updated 07/01/15)
106
Drug Name
Drug Status
Drug Details
pharmacist choice alcohol
Tier 3
pharmacist choice lancets
Tier 1
PHARMACY COUNTER LANCETS
Tier 3
PIKO 1
Tier 3
pillow mask/adult
Tier 3
pillow mask/child
Tier 3
pillow mask/pediatric
Tier 3
plastic adapter
Tier 3
POCKET CHAMBER
Tier 3
POCKET PEAK FLOW METER
Tier 3
POCKET SPACER
Tier 3
POCKETCHEM EZ CONTROL
Tier 3
POCKETPEAK PEAK FLOW METER
Tier 3
PRECISION GLUCOSE CONTROL
Tier 3
PRECISION GLUCOSE CONTROL SOLN
Tier 3
PRECISION GLUCOSE KETONE CONTR
Tier 3
PRECISION GLUCOSE/KETONE CONTR
Tier 3
PRECISION SUREDOSE PLUS SYR
Tier 3
PRECISION SURE-DOSE SYRINGE
Tier 3
PRECISION THIN LANCETS
Tier 3
PRECISION THINS GP LANCETS
Tier 3
PRECISION ULTRA LANCET
Tier 3
preferred plus lancets colored
Tier 1
preferred plus lancets thin
Tier 1
preferred plus unifine pentips
Tier 3
PRENTIF CAVITY-RIM CERV CAP
Tier 3
PA; QL
PRENTIF FITTING SET
Tier 3
PA; QL
PRESTIGE GLUCOSE CONTROL
Tier 3
PRODIGY CONTROL SOLUTION
Tier 3
PRODIGY INSULIN PEN NEEDLES
Tier 3
PRODIGY INSULIN SYRINGE
Tier 3
PRODIGY LANCETS 21G
Tier 3
PRODIGY LANCETS 26G
Tier 3
PRODIGY LANCETS 28G
Tier 3
PRODIGY LANCING DEVICE
Tier 3
PRODIGY MINI PEN NEEDLES
Tier 3
PRODIGY SAFETY LANCETS 26G
Tier 3
PRODIGY SHORT PEN NEEDLES
Tier 3
(Updated 07/01/15)
107
Drug Name
Drug Status
PRODIGY TWIST TOP LANCETS 28G
Tier 3
PSS SELECT GP LANCETS
Tier 3
PSS SELECT PLATFORMS
Tier 3
PSS SELECT SAFETY LANCETS
Tier 3
px advanced lancing device
Tier 3
px extra short pen needles
Tier 3
px insulin syringe 30g x 1/2" 0.3 ml, 30g x 1/2" 1 ml
Tier 2
px lancet auto injector
Tier 3
px lancets
Tier 1
px lancets ultra thin
Tier 1
px pen needle
Tier 3
px shortlength pen needles
Tier 3
qc advanced lancing device
Tier 3
qc alcohol swabs
Tier 3
qc insulin syringe 29g 0.3 ml, 29g 0.5 ml, 29g 1 ml,
30g 0.5 ml, 30g 1 ml
Tier 3
qc lancets super thin 30g
Tier 1
qc lancets ultra thin
Tier 1
qc pen needles
Tier 3
qc unifine pentips
Tier 3
QUICKTEK CONTROL SOLUTION
Tier 3
QUINTET CONTROL HIGH/NORMAL
Tier 3
ra alcohol swabs
Tier 3
RA E-ZJECT COLOR LANCETS 33G
Tier 3
RA E-ZJECT LANCETS 28G
Tier 3
RA E-ZJECT LANCETS THIN 26G
Tier 3
RA E-ZJECT LANCETS THIN 28G
Tier 3
RA E-ZJECT LANCETS ULTRA THIN
Tier 3
ra lancing device
Tier 3
ra pen needles
Tier 3
reality lancets
Tier 1
reality swabs
Tier 3
reality trigger lancets
Tier 1
REFUAH PLUS GLUCOSE CONTROL
Tier 3
RELION ALCOHOL SWABS
Tier 3
RELION INSULIN SYRINGE
Tier 3
RELI-ON INSULIN SYRINGE
Tier 3
RELION LANCETS MICRO-THIN 33G
Tier 3
Drug Details
RELION LANCETS STANDARD 21G
Tier 3
(Updated 07/01/15)
108
Drug Name
Drug Status
RELION LANCETS THIN 26G
Tier 3
RELION LANCETS ULTRA-THIN 30G
Tier 3
RELION LANCING DEVICE
Tier 3
RELION MINI PEN NEEDLES
Tier 3
RELION PEN NEEDLES
Tier 3
RELION SHORT PEN NEEDLES
Tier 3
RELION ULTRA THIN LANCETS 30G
Tier 3
RELION ULTRA THIN PLUS LANCETS
Tier 3
RENEW ADV CARTRIDGE REFILLS
Tier 3
RENEW ADVANCED LANCING DEVICE
Tier 3
replacement air filter
Tier 3
replacement filters
Tier 3
REXALL LANCETS ULTRA THIN 30G
Tier 3
RIGHTEST ALTERNATE SITE ADAPT
Tier 3
RIGHTEST GC300 CONTROL
Tier 3
RIGHTEST GD500 LANCING DEVICE
Tier 3
RIGHTEST GL300 LANCETS
Tier 3
RITEFLO
Tier 3
SAFESNAP INSULIN SYRINGE
Tier 3
SAFE-T-LANCE
Tier 3
SAFE-T-LANCE PLUS
Tier 3
safety lancet 21g/pressure act
Tier 3
safety lancet 28g/pressure act
Tier 3
SAFETY LANCET 2MM
Tier 3
SAFETY LANCETS
Tier 3
SAFETY LANCETS 21G
Tier 3
safety lancets 28g
Tier 1
SAFETY LET LANCETS
Tier 3
SAFETY SEAL LANCETS
Tier 3
SAFETY-GLIDE SYRINGE
Tier 3
SAMI THE SEAL FILTERS
Tier 3
sb alcohol prep
Tier 3
sb lancets thin
Tier 1
sb lancets ultra thin
Tier 1
select-lite device/lancets
Tier 1
select-lite lancing device
Tier 3
SHOPKO ALCOHOL SWABS
Tier 3
SHOPKO AUTOLET LANCING DEVICE
Tier 3
Drug Details
(Updated 07/01/15)
109
Drug Name
Drug Status
SHOPKO ON-THE-GO LANCETS 30G
Tier 3
SHOPKO UNIFINE PENTIPS
Tier 3
SHOPKO UNILET LANCETS 28G
Tier 3
SHOPKO UNILET LANCETS 30G
Tier 3
SIDESTREAM ADULT FACE MASK
Tier 3
SIDESTREAM PEDIATRIC FACE MASK
Tier 3
SIDESTREAM PLS ADULT FACE MASK
Tier 3
silicone mask/adult
Tier 3
silicone mask/infant
Tier 3
silicone mask/pediatric
Tier 3
SIMPLE DIAGNOSTICS LANCING DEV
Tier 3
SINGLE-LET
Tier 3
sm alcohol prep
Tier 3
sm lancets 21g
Tier 1
sm lancets 33g
Tier 1
sm super thin lancets 30g
Tier 1
sm thin lancets 26g
Tier 1
SMART DIABETES VANTAGE LANCETS
Tier 3
SMART DIABETES VANTAGE LANCING
Tier 3
SMART SENSE COLOR LANCETS 33G
Tier 3
SMART SENSE STANDARD LANCETS
Tier 3
SMART SENSE SUPER THIN LANCETS
Tier 3
SMART SENSE THIN LANCETS 26G
Tier 3
SMARTEST CONTROL MEDIUM
Tier 3
SMARTEST LANCETS 28G
Tier 3
SOLARTEK GLUCOSE CONTROL
Tier 3
SOLUS V2 CONTROL
Tier 3
SOLUS V2 LANCETS 28G
Tier 3
SOLUS V2 LANCING DEVICE
Tier 3
SOLUS V2 TWIST LANCETS 30G
Tier 3
STERILANCE PA
Tier 3
STERILANCE TL
Tier 3
super thin lancets
Tier 1
supreme ii high/low control
Tier 3
sure comfort alcohol prep
Tier 3
sure comfort insulin syringe 30g x 1/2" 0.3 ml, 30g x
1/2" 1 ml
Tier 2
sure comfort lancets 28g
Tier 1
Drug Details
sure comfort lancets 30g
Tier 1
(Updated 07/01/15)
110
Drug Name
Drug Status
sure comfort lancing pen
Tier 3
sure comfort pen needles 29g x 12.7mm , 30g x 8 mm
, 31g x 5 mm , 31g x 8 mm , 32g x 4 mm
Tier 3
SURE EDGE GLUCOSE CONTROL
Tier 3
SURECHEK CONTROL SOLUTION
Tier 3
SURE-FINE PEN NEEDLES
Tier 3
SURE-JECT INSULIN SYRINGE
Tier 3
SURE-LANCE FLAT LANCETS
Tier 3
SURE-LANCE LANCETS 26G
Tier 3
SURE-LANCE THIN LANCETS 28G
Tier 3
SURE-LANCE ULTRA THIN LANCETS
Tier 3
SURELITE LANCETS
Tier 3
SURE-PEN
Tier 3
SURE-PREP ALCOHOL PREP
Tier 3
SURESTEP GLUCOSE CONTROL
Tier 3
SURESTEP PRO HIGH GLUCOSE
Tier 3
SURESTEP PRO LOW GLUCOSE
Tier 3
SURESTEP PRO NORMAL GLUCOSE
Tier 3
SURE-TEST EASYPLUS CONTROL
Tier 3
SURE-TOUCH LANCETS UNIVERSAL
Tier 3
tai doc control
Tier 3
TECHLITE AST LANCETS
Tier 3
TECHLITE LANCETS
Tier 3
TECHLITE LANCETS 30G
Tier 3
TELCARE GLUCOSE CONTROL
Tier 3
TERUMO INSULIN SYRINGE 27G X 1/2" 1
ML
Tier 2
TERUMO INSULIN SYRINGE 28G X 1/2" 0.5
ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X
1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 3/8" 0.3
ML, 30G X 3/8" 0.5 ML, 30G X 3/8" 1 ML
Tier 3
TERUMO SURGUARD INSULIN SYR
Tier 3
tgt advanced lancing device
Tier 3
tgt alcohol swabs
Tier 3
tgt lancet alternate site
Tier 3
tgt lancet micro thin 33g
Tier 3
tgt lancet super thin 30g
Tier 3
tgt lancet thin 23g
Tier 3
tgt lancet thin 26g
Tier 3
Drug Details
tgt lancet ultra thin 28g
Tier 3
(Updated 07/01/15)
111
Drug Name
Drug Status
tgt lancet ultra thin 30g
Tier 3
tgt lancing device
Tier 3
THINLETS GP LANCETS
Tier 3
THINLETS LANCET
Tier 3
THINPRO INSULIN SYRINGE
Tier 3
THRESHOLD IMT
Tier 3
todays health lancing device
Tier 3
todays health mini pen needles
Tier 3
todays health pen needles
Tier 3
todays health short pen needle
Tier 3
todays health thin lancets 28g
Tier 1
todays health thin lancets 30g
Tier 1
topcare clickfine pen needles
Tier 3
TRUECONTROL GLUCOSE CONT LEV 0
Tier 3
TRUECONTROL GLUCOSE CONT LEV 1
Tier 3
TRUEDRAW LANCING DEVICE
Tier 3
TRUEPLUS INSULIN SYRINGE
Tier 3
TRUEPLUS LANCETS 26G
Tier 3
Tier 3
Tier 3
Tier 3
TRUEPLUS SAFETY LANCETS 28G
Tier 3
TRUETEST CONTROL LEVEL 1
Tier 3
Tier 3
Tier 3
TRUETRACK GLUCOSE CONTROL
Tier 3
TRUZONE PEAK FLOW METER
Tier 3
tubing/wing tip
Tier 3
ULTICARE INSULIN SAFETY SYR
Tier 3
ULTICARE INSULIN SYRINGE 28G X 1/2" 0.5
ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X
1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3
ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G
X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16"
1 ML
Tier 3
ULTICARE INSULIN SYRINGE 30G X 1/2" 0.3
ML, 30G X 1/2" 1 ML
Tier 2
ULTICARE MICRO PEN NEEDLES
Tier 3
ULTICARE MINI PEN NEEDLES
Tier 3
ULTICARE PEN NEEDLES
Tier 3
Drug Details
(Updated 07/01/15)
112
Drug Name
Drug Status
ULTICARE SHORT PEN NEEDLES
Tier 3
ULTICARE THIN LANCETS 30G
Tier 3
ULTI-LANCE AUTO-ADJUST DEVICE
Tier 3
ULTI-LANCE AUTOMATIC
Tier 3
ULTI-LANCE MINI ADJUSTABLE
Tier 3
ultilet alcohol swab
Tier 3
ultilet alcohol swabs
Tier 3
ULTILET BASIC LANCETS 30G
Tier 3
ULTILET CLASSIC LANCETS
Tier 3
ULTILET INSULIN SYRINGE
Tier 3
ULTILET INSULIN SYRINGE SHORT 30G X
5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1
ML
Tier 3
ULTILET LANCETS
Tier 3
ULTILET OPERATING DEVICE
Tier 3
ULTILET SAFETY LANCETS 23G
Tier 3
ULTILET ULTI-LANCE ADJ DEVICE
Tier 3
ultra comfort insulin syringe 30g x 1/2" 1 ml
Tier 2
ultra thin lancets 28g
Tier 1
ultra thin lancets 30g
Tier 1
ULTRALANCE
Tier 3
ULTRA-THIN II AUTO LANCET
Tier 3
ULTRA-THIN II INS SYR SHORT
Tier 3
ULTRA-THIN II INSULIN SYRINGE
Tier 3
ULTRA-THIN II LANCETS
Tier 3
ULTRA-THIN II MINI PEN NEEDLE
Tier 3
ULTRA-THIN II PEN NEEDLE SHORT
Tier 3
ULTRA-THIN II PEN NEEDLES
Tier 3
ULTRATRAK PRO CONTROL
Tier 3
ULTRATRAK ULTIMATE CONTROL
Tier 3
UNIFINE PENTIPS
Tier 3
unifine pentips plus 32g x 4 mm
Tier 3
UNILET COMFORTOUCH LANCET
Tier 3
UNILET EXCELITE
Tier 3
UNILET EXCELITE II
Tier 3
UNILET G.P. LANCET
Tier 3
UNILET G.P. SUPERLITE LANCET
Tier 3
UNILET GP 28 ULTRA THIN
Tier 3
UNILET LANCET
Tier 3
Drug Details
(Updated 07/01/15)
113
Drug Name
Drug Status
UNILET SUPERLITE LANCET
Tier 3
UNISTIK 1
Tier 3
UNISTIK 2
Tier 3
UNISTIK 2 COMFORT
Tier 3
UNISTIK 2 EXTRA
Tier 3
UNISTIK 2 NEONATAL
Tier 3
UNISTIK 2 NORMAL
Tier 3
UNISTIK 2 SUPER
Tier 3
UNISTIK 3
Tier 3
UNISTIK 3 COMFORT
Tier 3
UNISTIK 3 EXTRA
Tier 3
UNISTIK 3 GENTLE
Tier 3
UNISTIK 3 NEONATAL
Tier 3
UNISTIK 3 NORMAL
Tier 3
UNISTIK CZT COMFORT
Tier 3
UNISTIK CZT NORMAL
Tier 3
UNISTRIP CONTROL
Tier 3
UNIVERSAL 1 LANCETS THIN 26G
Tier 3
UNIVERSAL 1 LANCETS ULTRA THIN
Tier 3
value plus lancet standard 21g
Tier 3
value plus lancets super thin
Tier 1
value plus lancets thin 26g
Tier 1
value plus lancing device
Tier 3
valumark lancet super thin 30g
Tier 3
valumark lancet ultra thin 28g
Tier 3
valumark pen needles
Tier 3
valved holding chamber
Tier 3
VANISHPOINT INSULIN SYRINGE 29G X
1/2" 1 ML
Tier 3
VICTORY CONTROL LEVEL 1/2
Tier 3
VIDA MIA AUTOLET LANCING DEV
Tier 3
VIDA MIA UNIFINE PENTIPS
Tier 3
VIDA MIA UNILET LANCETS 28G
Tier 3
VIDA MIA UNILET LANCETS 30G
Tier 3
VITALET PRO LANCETS
Tier 3
VITALET PRO PLUS LANCETS
Tier 3
VOCAL POINT CONTROL
Tier 3
VORTEX VALVED HOLDING CHAMBER
Tier 3
Drug Details
V-R MONO INSULIN SYRINGE
Tier 3
(Updated 07/01/15)
114
Drug Name
Drug Status
W&F LANCETS 26G
Tier 3
W&F LANCETS COLORED 21G
Tier 3
walgreens adv travel lancets
Tier 1
WALGREENS LANCETS
Tier 3
walgreens lancets micro thin
Tier 1
walgreens lancets super thin
Tier 1
WALGREENS LANCING DEVICE
Tier 3
WALGREENS THIN LANCETS
Tier 3
WALGREENS ULTRA THIN LANCETS
Tier 3
WATCHHALER
Tier 3
WEBCOL ALCOHOL PREP LARGE
Tier 3
WEBCOL ALCOHOL PREP MEDIUM
Tier 3
wegmans unifine pentips plus
Tier 3
Drug Details
WIDE-SEAL DIAPHRAGM 60
CE
QL
CE
QL
CE
QL
CE
QL
CE
QL
CE
QL
CE
QL
CE
QL
WINDMILL TRAINER
Tier 3
XPRES CONTROL
Tier 3
*MIGRAINE PRODUCTS*
AMERGE
Tier 3
QL
AXERT
Tier 3
ST; N1; #; QL
CAFERGOT
Tier 3
CAMBIA
Tier 3
D.H.E. 45
Tier 3
dihydroergotamine mesylate injection
Tier 1
EPIDRIN
Tier 1
ERGOMAR
Tier 3
FROVA
Tier 3
ST; N1; #; QL
IMITREX NASAL
Tier 3
QL
IMITREX ORAL
Tier 3
QL
IMITREX STATDOSE SYSTEM
Tier 3
QL
IMITREX SUBCUTANEOUS*
Tier 3
QL
isometheptene-apap-dichloral
Tier 1
QL
(Updated 07/01/15)
115
Drug Name
Drug Status
Drug Details
MAXALT
Tier 3
QL
MAXALT-MLT
Tier 3
QL
MIGERGOT
Tier 3
migragesic ida
Tier 1
MIGRAL
Tier 3
MIGRALAM
Tier 3
MIGRANAL
Tier 3
ST; N1; QL
naratriptan hcl
Tier 1
QL
NODOLOR
Tier 1
PRODRIN ORAL TABLET 65-20-325 MG
Tier 3
RELPAX
Tier 3
ST; N1; QL
rizatriptan benzoate
Tier 1
QL
sumatriptan succinate oral
Tier 1
QL
sumatriptan succinate subcutaneous* 4 mg/0.5ml, 6
mg/0.5ml
Tier 1
QL
SUMAVEL DOSEPRO SUBCUTANEOUS* 4
MG/0.5ML
Tier 3
ST; QL
SUMAVEL DOSEPRO SUBCUTANEOUS* 6
MG/0.5ML
Tier 3
ST; N1; QL
TREXIMET
Tier 3
ST; N1; QL
zolmitriptan oral
Tier 1
QL
ZOMIG NASAL
Tier 3
ST; N1; QL
ZOMIG ORAL
Tier 3
QL
ZOMIG ZMT
Tier 3
ST; N1; QL
*MINERALS & ELECTROLYTES*
CALCIFOL
Tier 3
calcium-folic acid plus d
Tier 3
EFFER-K ORAL TABLET EFFERVESCENT 10
MEQ, 20 MEQ
Tier 3
EFFER-K ORAL TABLET EFFERVESCENT 25
MEQ
Tier 1
effervescent pot chloride
Tier 1
EPIFLUR
Tier 1
EPIKLOR
Tier 1
FLUORABON
CE
FLUOR-A-DAY ORAL SOLUTION
Tier 1
FLUOR-A-DAY ORAL TABLET CHEWABLE
0.25 (F)-236.79 MG
Tier 3
FLUOR-A-DAY ORAL TABLET CHEWABLE
0.5 (F)-236.79 MG, 1 (F)-236.79 MG
CE
(Updated 07/01/15)
116
Drug Name
Drug Status
fluoritab oral solution
Tier 1
fluoritab oral tablet chewable 0.55 (0.25 f) mg
Tier 1
fluoritab oral tablet chewable 1.1 (0.5 f) mg, 2.2 (1
f) mg
CE
FLURA-DROPS ORAL SOLUTION 0.275 (0.125
F) MG/DROP
Tier 1
FLURA-DROPS ORAL SOLUTION 0.55 (0.25
F) MG/DROP
Drug Details
CE
GALZIN
Tier 3
KARIDIUM
Tier 1
k-effervescent
Tier 1
KLOR-CON 10
Tier 1
KLOR-CON M10
Tier 1
KLOR-CON M15
Tier 3
KLOR-CON M20
Tier 1
KLOR-CON ORAL PACKET 20 MEQ
Tier 1
KLOR-CON ORAL PACKET 25 MEQ
Tier 3
KLOR-CON ORAL TABLET
EXTENDEDRELEASE*
Tier 1
KLOR-CON/EF
Tier 1
K-PHOS
Tier 3
K-PRIME
Tier 1
k-vescent
Tier 1
LOZI-FLUR
Tier 3
LUDENT
CE
MICRO-K
Tier 3
NAFRINSE
Tier 1
NAFRINSE DROPS
Tier 1
PHOSPHA 250 NEUTRAL
Tier 1
pot bicarb-pot chloride
Tier 1
potassium bicarbonate oral
Tier 1
potassium chloride crys er oral tablet
extendedrelease* 10 meq
Tier 1
potassium chloride crys er oral tablet
extendedrelease* 20 meq
Tier 1
potassium chloride er oral capsule extended release*
10 meq
Tier 1
potassium chloride er oral capsule extended release*
8 meq
Tier 1
LGC
LGC
LGC
LGC
potassium chloride er oral tablet extendedrelease* 10
Tier 1
meq, 8 meq
(Updated 07/01/15)
117
Drug Name
Drug Status
potassium chloride oral liquid† 20 meq/15ml (10%)
Tier 1
potassium chloride oral packet
Tier 1
potassium chloride oral solution
Tier 1
sodium fluoride oral solution
CE
sodium fluoride oral tablet 2.2 (1 f) mg
CE
sodium fluoride oral tablet chewable 0.55 (0.25 f)
mg
CE
sodium fluoride oral tablet chewable 1.1 (0.5 f) mg,
2.2 (1 f) mg
CE
SSKI
Drug Details
LGC
LGC
Tier 3
*MOUTH/THROAT/DENTAL AGENTS*
AQUORAL
Tier 3
CAVAREST
Tier 1
cevimeline hcl
Tier 1
chlorhexidine gluconate mouth/throat
Tier 1
CLINPRO 5000
Tier 1
clotrimazole mouth/throat
Tier 1
CONTROLRX
Tier 1
DEBACTEROL
Tier 3
DENTA 5000 PLUS
Tier 1
DENTAGEL
Tier 1
dentall 1100 plus
Tier 1
EVOXAC
Tier 3
FLUORIDEX DAILY DEFENSE
Tier 1
FLUORIDEX ENHANCED WHITENING
Tier 1
FLUORIDEX SENSITIVITY RELIEF DENTAL
Tier 3
FLUORIDEX SENSITIVITY RELIEF DENTAL
PASTE
Tier 1
GELCLAIR
Tier 3
GELX
Tier 3
KARIGEL
Tier 1
KARIGEL-N
Tier 1
lidocaine hcl mouth/throat
Tier 1
lidocaine viscous
Tier 1
LTA 360 KIT
Tier 3
MUCOTROL
Tier 3
NAFRINSE DAILY ACIDULATED
Tier 3
NAFRINSE DAILY/NEUTRAL
Tier 3
NAFRINSE WEEKLY
Tier 3
(Updated 07/01/15)
118
Drug Name
Drug Status
NEUTRAGARD ADVANCED
Tier 1
NEUTRASAL
Tier 3
nystatin mouth/throat
Tier 1
ORAFATE
Tier 3
ORALONE
Tier 1
ORAMAGICRX
Tier 3
ORAVIG
Tier 3
PERIDEX
Tier 3
PERIOGARD
Tier 1
PERIOMED
Tier 1
PHOS-FLUR
Tier 1
pilocarpine hcl oral
Tier 1
PREVIDENT 5000 BOOSTER
Tier 3
PREVIDENT 5000 BOOSTER PLUS
Tier 3
PROTHELIAL
Tier 3
SALAGEN
Tier 3
SALICEPT
Tier 3
sf
Tier 1
sf 5000 plus
Tier 1
stannous fluoride mouth/throat
Tier 1
triamcinolone acetonide mouth/throat
Tier 1
Drug Details
QL
*MULTIVITAMINS*
active ob
Tier 3
advanced am/pm
Tier 3
APETIMAR/IRON
Tier 2
ATABEX EC
Tier 3
ATABEX ORAL TABLET
Tier 3
BAL-CARE DHA
Tier 3
B-NEXA
Tier 3
CAVAN-FOLATE OB
Tier 3
CITRANATAL 90 DHA
Tier 3
CITRANATAL B-CALM
Tier 3
CITRANATAL DHA
Tier 3
CITRANATAL HARMONY
Tier 3
CITRANATAL RX
Tier 3
c-nate dha
Tier 3
completenate
Tier 3
complete-rf prenatal
Tier 3
(Updated 07/01/15)
119
Drug Name
Drug Status
CO-NATAL FA
Tier 3
CONCEPT DHA
Tier 3
CONCEPT OB
Tier 3
corenate-dha
Tier 3
CORVITA
Tier 1
CRNATAL
Tier 3
DIALYVITE
Tier 1
DIALYVITE 3000
Tier 3
DIALYVITE 5000
Tier 3
DIALYVITE SUPREME D
Tier 3
DIALYVITE/ZINC
Tier 3
DUET DHA
Tier 3
DUET DHA 400
Tier 3
DUET DHA 400EC
Tier 3
DUET DHA 430
Tier 3
DUET DHA 430EC
Tier 3
DUET DHA BALANCED ORAL 25-1 & 267
MG, 27-1 & 380 MG, 27-1 & 430 MG
Tier 3
DUET DHA EC
Tier 3
ELITE-OB
Tier 3
ELITE-OB 400
Tier 3
ESCAVITE
Tier 3
extra-virt plus dha
Tier 3
focalgin-b
Tier 3
folbee plus
Tier 1
FOLBEE PLUS CZ
Tier 1
folcal dha
Tier 3
FOLCAPS OMEGA 3
Tier 3
FOLGARD OS
Tier 3
FOLIVANE-EC CALCIUM DHA NF
Tier 3
FOLIVANE-OB
Tier 3
FOLIVANE-PRX DHA NF
Tier 3
GESTICARE DHA
Tier 3
hemenatal ob
Tier 3
hemenatal ob + dha
Tier 3
INATAL ADVANCE
Tier 3
INATAL GT
Tier 3
INATAL ULTRA
Tier 3
Drug Details
infanate balance
Tier 3
(Updated 07/01/15)
120
Drug Name
Drug Status
LACTOCAL-F
Tier 3
levomefolate dha
Tier 3
l-methylfolate pnv dha
Tier 3
MACNATAL CN DHA
Tier 3
MARNATAL-F
Tier 3
multi vit/fl
Tier 1
multi vita-bets/fluoride
Tier 1
multi vitamin/fluoride
Tier 1
multiple vitamins/fluoride
Tier 1
multi-vit/fluoride
Tier 1
multi-vit/fluoride/iron
Tier 3
multivitamin/fluoride
Tier 1
multi-vitamin/fluoride
Tier 1
multi-vitamin/fluoride/iron
Tier 3
multivitamins/fluoride
Tier 1
multi-vitamins/fluoride
Tier 1
multi-vits/fluoride
Tier 1
mult-vitamin/fluoride
Tier 1
MVC-FLUORIDE
Tier 1
MYKIDZ IRON FL
Tier 3
MYNATAL
Tier 3
MYNATAL ADVANCE
Tier 3
mynephrocaps
Tier 1
NATACHEW
Tier 3
natal-v rx
Tier 3
NATALVIRT 90 DHA
Tier 3
NATALVIRT CA
Tier 3
NATALVIT
Tier 3
NATELLE ONE
Tier 3
NEEVO DHA ORAL CAPSULE 27-1.13 MG
Tier 3
NEPHPLEX RX
Tier 3
NEPHROCAPS
Tier 3
NEPHROCAPS QT
Tier 3
NEPHRONEX ORAL TABLET
Tier 1
NESTABS
Tier 3
NESTABS ABC
Tier 3
NESTABS DHA
Tier 3
NEXA PLUS
Tier 3
Drug Details
(Updated 07/01/15)
121
Drug Name
Drug Status
NEXA SELECT ORAL CAPSULE 29-1.25-325
MG
Tier 3
NICOMIDE
Tier 3
nutri-tab ob + dha
Tier 3
NUTRIVIT
Tier 3
OB COMPLETE
Tier 3
OB COMPLETE 400
Tier 3
OB COMPLETE ONE
Tier 3
OB COMPLETE PETITE
Tier 3
OB COMPLETE PREMIER
Tier 3
OB COMPLETE/DHA
Tier 3
OB-NATAL ONE ORAL CAPSULE 27-1 MG
Tier 3
O-CAL PRENATAL
Tier 3
OCUVEL
Tier 3
PAIRE OB
Tier 3
pnv fe fum/docusate/folic acid
Tier 3
pnv ob+dha
Tier 3
pnv-dha
Tier 3
pnv-dha+docusate
Tier 3
pnv-first
Tier 3
pnv-omega
Tier 3
pnv-select
Tier 3
pnv-total
Tier 3
POLY-VI-FLOR
Tier 3
POLY-VI-FLOR/IRON
Tier 3
polyvitamin/fluoride
Tier 1
poly-vitamin/fluoride
Tier 1
PR NATAL 400
Tier 3
PREFERA OB
Tier 3
PREFERA OB + DHA
Tier 3
PREFERAOB ONE
Tier 3
PREFOL-DHA
Tier 3
prena1 pearl
Tier 3
prena1 plus/quatrefolic
Tier 3
prena1/quatrefolic
Tier 3
prenaissance
Tier 3
prenaissance 90 dha
Tier 3
prenaissance balance
Tier 3
Drug Details
prenaissance dha
Tier 3
(Updated 07/01/15)
122
Drug Name
Drug Status
prenaissance harmony dha
Tier 3
prenaissance next
Tier 3
prenaissance next-b
Tier 3
prenaissance plus
Tier 3
prenaissance promise
Tier 3
PRENATA
Tier 3
prenatabs fa
Tier 3
PRENATABS RX
Tier 3
prenatal 19
Tier 3
PRENATAL AD
Tier 3
PRENATAL MULTIVITAMIN-ULTRA
Tier 3
prenatal plus iron
Tier 3
prenatal+dha oral 27-1 & 250 mg
Tier 3
PRENATAL-U
Tier 3
PRENATE
Tier 3
PRENATE AM
Tier 3
PRENATE DHA ORAL CAPSULE
28-0.6-0.4-300 MG
Tier 3
PRENATE ELITE ORAL TABLET 26-0.6-0.4
MG, 27-0.6-0.4 MG
Tier 3
PRENATE ENHANCE
Tier 3
PRENATE ESSENTIAL ORAL CAPSULE
28-0.6-0.4-340 MG
Tier 3
PRENATE MINI
Tier 3
PRENATE RESTORE
Tier 3
PRENEXA
Tier 3
PREQUE 10
Tier 3
PROVIDA OB
Tier 3
purefe ob plus
Tier 3
QUFLORA PEDIATRIC ORAL SOLUTION
Tier 3
QUFLORA PEDIATRIC ORAL TABLET
CHEWABLE
Tier 1
reaphirm
Tier 3
relnate dha
Tier 3
RENAL ORAL CAPSULE
Tier 1
RENALPREN
Tier 1
RENATABS
Tier 3
RENATABS WITH IRON
Tier 3
rena-vite rx
Tier 1
Drug Details
(Updated 07/01/15)
123
Drug Name
Drug Status
RENAX ORAL TABLET 2.5 MG
Tier 3
reno caps
Tier 1
R-NATAL OB
Tier 3
SELECT-OB ORAL TABLET CHEWABLE 29-1
MG
Tier 3
SELECT-OB+DHA
Tier 3
se-natal 19
Tier 3
STROVITE FORTE ORAL SYRUP
Tier 2
SUPERVITE EC
Tier 3
SYNAGEX
Tier 3
SYNATEK
Tier 3
TANDEM DHA
Tier 3
TANDEM OB
Tier 3
TARON EC CALCIUM
Tier 3
TARON-BC
Tier 3
TARON-C DHA
Tier 3
TARON-PREX
Tier 3
TL G-FOL OS
Tier 3
tl-assure one
Tier 3
tl-care dha
Tier 3
tl-fluorivite
Tier 3
tl-select
Tier 3
tl-select dha
Tier 3
TRI RX
Tier 3
triadvance
Tier 3
TRICARE PRENATAL COMPLEAT
Tier 3
TRICARE PRENATAL DHA ONE
Tier 3
trinatal gt
Tier 3
trinatal ultra
Tier 3
TRINATE
Tier 3
triphrocaps
Tier 1
triple-vitamin/fluoride
Tier 1
tri-tabs dha
Tier 3
TRIVEEN-DUO DHA
Tier 3
TRIVEEN-ONE
Tier 3
TRIVEEN-PRX RNF
Tier 3
TRIVEEN-TEN
Tier 3
TRIVEEN-U
Tier 3
Drug Details
TRI-VI-FLOR
Tier 3
(Updated 07/01/15)
124
Drug Name
Drug Status
tri-vi-floro
Tier 3
tri-vit/fluoride
Tier 1
tri-vit/fluoride/iron
Tier 3
tri-vitamin/fluoride
Tier 1
UDAMIN SP
Tier 3
ultimatecare advantage
Tier 3
ultimatecare combo
Tier 3
ULTRA NATALCARE
Tier 3
ultra tabs
Tier 3
VEMAVITE-PRX 2
Tier 3
vena-bal dha
Tier 3
venatal complete dha
Tier 3
venatal-fa
Tier 3
VINACAL
Tier 3
VINACAL B
Tier 3
VINATE AZ EXTRA
Tier 3
VINATE CALCIUM
Tier 3
VINATE DHA RF
Tier 3
VINATE GT
Tier 3
VINATE IC
Tier 3
VINATE II
Tier 3
VINATE M
Tier 3
vinate ultra
Tier 3
virt-bal dha
Tier 3
virt-bal dha plus
Tier 3
virt-caps
Tier 1
virt-pn
Tier 3
virt-pn dha
Tier 3
virt-pn plus
Tier 3
virt-select
Tier 3
virt-vite plus
Tier 1
VITAFOL ORAL SYRUP
Tier 2
VITAFOL ULTRA
Tier 3
VITAFOL-NANO
Tier 3
VITAFOL-OB
Tier 3
VITAFOL-OB+DHA
Tier 3
VITAFOL-ONE
Tier 3
VITAFOL-PLUS
Tier 3
Drug Details
(Updated 07/01/15)
125
Drug Name
Drug Status
VITAFOL-PN
Tier 3
VITAL-D RX
Tier 3
VITAMEDMD ONE RX/QUATREFOLIC
Tier 3
VITAMEDMD PLUS RX/QUATREFOLIC
Tier 3
VITAMEDMD REDICHEW RX ORAL
TABLET CHEWABLE 0.6-0.4 MG
Tier 3
vitamins acd-fluoride
Tier 1
VITAPEARL
Tier 3
VITA-PREN
Tier 3
VIVA DHA
Tier 3
v-natal dha
Tier 3
vol-care rx
Tier 1
vol-nate
Tier 3
vol-tab rx
Tier 3
vp-ch plus
Tier 3
vp-ch-pnv
Tier 3
vp-ggr-b6 prenatal
Tier 3
vp-heme ob
Tier 3
vp-heme ob + dha
Tier 3
vp-heme one
Tier 3
vp-pnv-dha
Tier 3
ZATEAN-CH
Tier 3
ZATEAN-PN
Tier 3
ZATEAN-PN DHA
Tier 3
ZATEAN-PN PLUS
Tier 3
zingiber
Tier 3
Drug Details
*MUSCULOSKELETAL THERAPY AGENTS*
AMRIX
Tier 3
ST; N1
baclofen oral tablet 10 mg
Tier 1
LGC
baclofen oral tablet 20 mg
Tier 1
carisoprodol oral tablet 350 mg
Tier 1
carisoprodol-aspirin
Tier 1
carisoprodol-aspirin-codeine
Tier 1
chlorzoxazone oral
Tier 1
cyclobenzaprine hcl oral tablet 10 mg, 5 mg
Tier 1
cyclobenzaprine hcl oral tablet 7.5 mg
Tier 1
DANTRIUM ORAL
Tier 3
dantrolene sodium oral
Tier 1
LGC
ed baclofen
Tier 1
(Updated 07/01/15)
126
Drug Name
Drug Status
FEXMID
Tier 3
LORZONE
Tier 3
metaxalone
Tier 1
methocarbamol oral
Tier 1
orphenadrine citrate er
Tier 1
orphenadrine-aspirin-caffeine oral tablet 25-385-30
mg
Tier 1
PARAFON FORTE DSC
Tier 3
ROBAXIN ORAL
Tier 3
ROBAXIN-750
Tier 3
SKELAXIN
Tier 3
SOMA
Tier 3
SYNVISC ONE
Tier 3
THERABENZAPRINE-90-5
Tier 3
tizanidine hcl oral
Tier 1
ZANAFLEX
Tier 3
Drug Details
ST; N1
PA
*NASAL AGENTS - SYSTEMIC AND
TOPICAL*
ADRENALIN NASAL
Tier 3
ASTEPRO
Tier 3
ATROVENT
Tier 3
azelastine hcl nasal solution 0.1 %
Tier 1
azelastine hcl nasal solution 0.15 %
Tier 3
BACTROBAN NASAL
Tier 3
BECONASE AQ
Tier 3
budesonide nasal
Tier 3
DYMISTA
Tier 3
flunisolide nasal solution 25 mcg/act (0.025%)
Tier 1
fluticasone propionate nasal
Tier 1
ipratropium bromide nasal
Tier 1
NASONEX
Tier 2
olopatadine hcl
Tier 1
OMNARIS
Tier 3
PATANASE
Tier 3
QNASL
Tier 3
QNASL CHILDRENS
Tier 3
RHINOCORT AQUA
Tier 3
TYZINE
Tier 3
VERAMYST
Tier 3
ST; N1
ST
ST; N1
ST; N1
ST; N1
(Updated 07/01/15)
127
Drug Name
Drug Status
Drug Details
ZETONNA
Tier 3
ST; N1
BOTOX INJECTION SOLUTION
Tier 2
PA
BOTOX INJECTION SOLUTION
Tier 2
DYSPORT
Tier 3
PA
RILUTEK
Tier 3
PA; ST; N1
riluzole
Tier 1
PA
XEOMIN
Tier 3
PA
ACULAR
Tier 3
QL
ACULAR LS
Tier 3
QL
ACUVAIL
Tier 3
QL
AK-PENTOLATE
Tier 1
ak-poly-bac
Tier 1
AKTEN
Tier 3
ALCAINE
Tier 3
ALOCRIL
Tier 3
ALOMIDE
Tier 3
ALPHAGAN P
Tier 2
ALREX
Tier 2
ALTACAINE
Tier 1
ALTAFLUOR
Tier 1
ALTAFRIN
Tier 1
apraclonidine hcl
Tier 1
atropine sulfate ophthalmic solution
Tier 1
atropine-care
Tier 1
AZASITE
Tier 2
azelastine hcl ophthalmic
Tier 1
AZOPT
Tier 2
bacitracin-polymyxin b ophthalmic
Tier 1
bacitra-neomycin-polymyxin-hc
Tier 1
BEPREVE
Tier 3
BESIVANCE
Tier 3
BETADINE OPHTHALMIC PREP
Tier 3
BETAGAN
Tier 3
betaxolol hcl ophthalmic
Tier 1
BETIMOL
Tier 3
*NEUROMUSCULAR AGENTS*
*OPHTHALMIC AGENTS*
QL
(Updated 07/01/15)
128
Drug Name
Drug Status
Drug Details
BETOPTIC-S
Tier 3
bimatoprost ophthalmic
Tier 1
BIO GLO
Tier 1
BLEPHAMIDE
Tier 3
BLEPHAMIDE S.O.P.
Tier 3
brimonidine tartrate ophthalmic
Tier 1
carteolol hcl
Tier 1
CILOXAN OPHTHALMIC OINTMENT
Tier 3
CILOXAN OPHTHALMIC SOLUTION
Tier 3
QL
ciprofloxacin hcl ophthalmic
Tier 1
QL
COMBIGAN
Tier 2
COSOPT
Tier 3
COSOPT PF
Tier 3
cromolyn sodium ophthalmic
Tier 1
CYCLOGYL OPHTHALMIC SOLUTION 0.5 %,
2%
Tier 3
CYCLOMYDRIL
Tier 3
cyclopentolate hcl ophthalmic
Tier 1
cylate
Tier 1
CYSTARAN
Tier 3
dexamethasone sodium phosphate ophthalmic
Tier 1
diclofenac sodium ophthalmic
Tier 1
dorzolamide hcl
Tier 1
dorzolamide hcl-timolol mal
Tier 1
DUREZOL
Tier 2
ELESTAT
Tier 3
EMADINE
Tier 3
epinastine hcl
Tier 1
erythromycin ophthalmic
Tier 1
EYLEA
Tier 2
FLAREX
Tier 3
FLUCAINE
Tier 1
fluorescein-benoxinate
Tier 1
FLUOR-I-STRIPS A.T.
Tier 1
fluorometholone ophthalmic
Tier 1
FLURA-SAFE
Tier 3
flurbiprofen sodium
Tier 1
FLUROX
Tier 1
QL
QL
PA
QL
QL
FML
Tier 3
(Updated 07/01/15)
129
Drug Name
Drug Status
Drug Details
FML FORTE
Tier 3
FML LIQUIFILM
Tier 3
FUL-GLO OPHTHALMIC STRIP 0.6 MG
Tier 3
FUL-GLO OPHTHALMIC STRIP 1 MG
Tier 1
GARAMYCIN OPHTHALMIC OINTMENT
Tier 1
GARAMYCIN OPHTHALMIC SOLUTION
Tier 3
QL
gatifloxacin
Tier 1
QL
GELFILM OPHTHALMIC
Tier 3
GENTAK
Tier 1
gentamicin sulfate ophthalmic ointment
Tier 1
gentamicin sulfate ophthalmic solution
Tier 1
HOMATROPAIRE
Tier 1
homatropine hbr ophthalmic
Tier 1
ILEVRO
Tier 3
ILOTYCIN
Tier 1
IOPIDINE
Tier 3
ISOPTO CARBACHOL
Tier 3
ISOPTO HOMATROPINE OPHTHALMIC
SOLUTION 2 %
Tier 3
ISOPTO HYOSCINE
Tier 3
ISTALOL
Tier 3
JETREA
Tier 2
ketorolac tromethamine ophthalmic
Tier 1
LACRISERT
Tier 3
LASTACAFT
Tier 3
latanoprost ophthalmic
Tier 1
levobunolol hcl ophthalmic solution 0.5 %
Tier 1
levofloxacin ophthalmic
Tier 1
LOTEMAX OPHTHALMIC
Tier 2
LOTEMAX OPHTHALMIC OINTMENT
Tier 3
LOTEMAX OPHTHALMIC SUSPENSION
Tier 2
LUCENTIS
Tier 2
LUMIGAN OPHTHALMIC SOLUTION 0.01 %
Tier 3
MACUGEN
Tier 3
MAXIDEX
Tier 3
MAXITROL OPHTHALMIC OINTMENT
Tier 3
MAXITROL OPHTHALMIC SUSPENSION
Tier 3
metipranolol
Tier 3
QL
QL
QL
QL
ST; N1; QL
QL
MITOSOL
Tier 3
(Updated 07/01/15)
130
Drug Name
Drug Status
Drug Details
MOXEZA
Tier 3
mydral
Tier 1
MYDRIACYL
Tier 3
NATACYN
Tier 3
NEOFRIN
Tier 1
neomycin-bacitracin zn-polymyx
Tier 1
neomycin-polymyxin-dexameth ophthalmic ointment
Tier 1
neomycin-polymyxin-dexameth ophthalmic
suspension 3.5-10000-0.1
Tier 1
QL
neomycin-polymyxin-gramicidin
Tier 1
QL
NEO-POLYCIN
Tier 1
NEO-POLYCIN HC
Tier 1
NEOSPORIN
Tier 3
QL
NEVANAC
Tier 3
QL
OCUFEN
Tier 3
QL
OCUFLOX
Tier 3
QL
ofloxacin ophthalmic
Tier 1
QL
OMNIPRED
Tier 3
OPTIPRANOLOL
Tier 3
OPTIVAR
Tier 3
OZURDEX
Tier 2
parcaine
Tier 1
PAREMYD
Tier 3
PATADAY
Tier 2
PATANOL
Tier 3
PAZEO
Tier 2
phenylephrine hcl ophthalmic solution 10 %, 2.5 %
Tier 1
PHOSPHOLINE IODIDE
Tier 3
pilocarpine hcl ophthalmic
Tier 1
PILOPINE HS
Tier 3
POLYCIN
Tier 1
polycin b
Tier 1
poly-dex
Tier 1
polymyxin b-trimethoprim
Tier 1
QL
POLYTRIM
Tier 3
QL
PRED FORTE
Tier 3
PRED MILD
Tier 3
PRED-G
Tier 3
QL
QL
ST; N1; #
QL
PRED-G S.O.P.
Tier 3
(Updated 07/01/15)
131
Drug Name
Drug Status
Drug Details
prednisolone acetate ophthalmic
Tier 1
PROLENSA
Tier 3
proparacaine hcl ophthalmic
Tier 1
proparacaine-fluorescein
Tier 1
RESCULA
Tier 3
RESTASIS
Tier 2
romycin
Tier 1
ROSE GLO
Tier 3
SIMBRINZA
Tier 3
sulfacetamide sodium ophthalmic solution
Tier 1
sulfacetamide-prednisolone ophthalmic solution
Tier 1
TETCAINE
Tier 1
tetracaine hcl ophthalmic
Tier 1
TETRAVISC
Tier 1
TETRAVISC FORTE
Tier 1
timolol maleate ophthalmic
Tier 1
TIMOPTIC
Tier 3
TIMOPTIC OCUDOSE
Tier 3
TIMOPTIC-XE
Tier 3
TOBRADEX OPHTHALMIC OINTMENT
Tier 3
TOBRADEX OPHTHALMIC SUSPENSION
Tier 3
QL
TOBRADEX ST
Tier 3
QL
tobramycin ophthalmic
Tier 1
QL
tobramycin-dexamethasone
Tier 1
QL
tobrasol
Tier 1
QL
TOBREX OPHTHALMIC OINTMENT
Tier 3
TOBREX OPHTHALMIC SOLUTION
Tier 3
QL
TRAVATAN Z
Tier 2
QL
travoprost
Tier 3
ST; N1; QL
trifluridine ophthalmic
Tier 1
QL
triple antibiotic ophthalmic
Tier 1
tropicamide ophthalmic
Tier 1
TRUSOPT
Tier 3
VEXOL
Tier 3
VIGAMOX
Tier 3
QL
VIROPTIC
Tier 3
QL
VISUDYNE
Tier 3
XALATAN
Tier 3
ST; N1; QL
QL
ST; N1; QL
(Updated 07/01/15)
132
Drug Name
Drug Status
Drug Details
ZADITOR
Tier 1
LGC
ZIOPTAN
Tier 3
ST; N1; QL
ZIRGAN
Tier 3
ZYLET
Tier 3
QL
ZYMAXID
Tier 3
QL
*OTIC AGENTS*
a/b otic
Tier 1
ACETASOL HC
Tier 1
acetic acid otic
Tier 1
AERO OTIC HC
Tier 1
antibiotic ear
Tier 1
antipyrine-benzocaine
Tier 1
aurax
Tier 1
AURODEX
Tier 1
AUROGUARD
Tier 1
auroto
Tier 1
CETRAXAL
Tier 3
CIPRO HC
Tier 3
#; QL
CIPRODEX
Tier 2
QL
COLY-MYCIN S
Tier 3
QL
CORTANE-B OTIC
Tier 3
CORTIC-ND
Tier 1
CORTISPORIN OTIC
Tier 3
QL
CORTISPORIN-TC
Tier 3
QL
CRESYLATE
Tier 3
CYOTIC
Tier 1
DERMOTIC
Tier 3
exotic-hc
Tier 1
fluocinolone acetonide otic
Tier 1
hydrocortisone-acetic acid
Tier 1
MYOXIN
Tier 3
neomycin-polymyxin-hc otic solution 1 %
Tier 1
neomycin-polymyxin-hc otic solution 3.5-10000-1
Tier 1
QL
neomycin-polymyxin-hc otic suspension
Tier 1
QL
ofloxacin otic
Tier 1
QL
otic care
Tier 1
oticin
Tier 1
OTICIN HC NR
Tier 3
QL
(Updated 07/01/15)
133
Drug Name
Drug Status
oto-end 10
Tier 1
otomar
Tier 1
otomax-hc
Tier 1
OTOZIN
Tier 3
pinnacaine otic
Tier 3
pramoxine-hc-chloroxylenol aq
Tier 1
VOSOL HC
Tier 3
zotane hc
Tier 1
Drug Details
*OXYTOCICS*
CERVIDIL
Tier 3
methylergonovine maleate oral
Tier 1
PREPIDIL
Tier 3
PROSTIN E2
Tier 3
*PASSIVE IMMUNIZING AGENTS*
CARIMUNE NF
Tier 3
PA
CYTOGAM
Tier 2
FLEBOGAMMA
Tier 3
PA
FLEBOGAMMA DIF INTRAVENOUS*
SOLUTION 0.5 GM/10ML, 10 GM/200ML, 2.5
GM/50ML, 20 GM/200ML, 20 GM/400ML, 5
GM/100ML
Tier 3
PA
GAMASTAN S/D
Tier 3
PA
GAMMAGARD INJECTION SOLUTION 30
GM/300ML
Tier 3
PA
GAMMAGARD S/D
Tier 3
PA
GAMMAGARD S/D LESS IGA
Tier 3
PA
GAMMAPLEX INTRAVENOUS* SOLUTION
10 GM/200ML, 2.5 GM/50ML, 5 GM/100ML
Tier 3
PA
GAMUNEX INTRAVENOUS* SOLUTION 20
GM/200ML
Tier 3
PA
GAMUNEX-C INJECTION SOLUTION 40
GM/400ML
Tier 2
PA
HEPAGAM B
Tier 2
HIZENTRA
Tier 3
HYPERHEP B S/D
Tier 3
HYPERTET S/D
Tier 2
HYQVIA
Tier 3
NABI-HB
Tier 3
OCTAGAM
Tier 3
PA
PA
PA
(Updated 07/01/15)
134
Drug Name
Drug Status
Drug Details
PRIVIGEN INTRAVENOUS* SOLUTION 20
GM/200ML, 40 GM/400ML
Tier 3
PA
SYNAGIS
Tier 2
PA
WINRHO SDF
Tier 3
*PENICILLINS*
amoxicillin oral capsule
Tier 1
amoxicillin oral suspension reconstituted
Tier 1
amoxicillin oral tablet
Tier 1
amoxicillin-pot clavulanate er
Tier 1
amoxicillin-pot clavulanate oral
Tier 1
ampicillin oral capsule
Tier 1
AUGMENTIN ES-600
Tier 3
AUGMENTIN ORAL SUSPENSION
RECONSTITUTED
Tier 3
AUGMENTIN ORAL TABLET
Tier 3
AUGMENTIN XR
Tier 3
dicloxacillin sodium
Tier 1
MOXATAG
Tier 3
penicillin v potassium
Tier 1
*PHARMACEUTICAL ADJUVANTS*
PCCA ACACIA SYRUP BASE
Tier 3
polyethylene glycol 3350 powder
Tier 1
LGC
*PROGESTINS*
AYGESTIN
Tier 3
MAKENA
Tier 3
PA; QL
medroxyprogesterone acetate oral
Tier 1
LGC
MEGACE ES
Tier 3
norethindrone acetate oral
Tier 1
progesterone intramuscular*
Tier 1
progesterone micronized oral
Tier 1
PROMETRIUM
Tier 3
PROVERA
Tier 3
*PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.*
acamprosate calcium
Tier 1
AMPYRA
Tier 3
ANTABUSE
Tier 3
ARICEPT
Tier 3
ST; N1
ARICEPT ODT
Tier 3
ST; N1
PA; QL
(Updated 07/01/15)
135
Drug Name
Drug Status
Drug Details
AUBAGIO
Tier 3
PA; QL
AVONEX
Tier 3
PA
AVONEX PEN
Tier 3
PA
AVONEX PREFILLED
Tier 3
PA
BETASERON
Tier 3
PA
BRISDELLE
Tier 3
ST; N1
BUPROBAN
CE
bupropion hcl er (smoking det)
CE
QL
CAMPRAL
Tier 3
CHANTIX
CE
QL
CHANTIX CONTINUING MONTH PAK
CE
QL
CHANTIX STARTING MONTH PAK
CE
QL
COPAXONE SUBCUTANEOUS* 40 MG/ML
Tier 2
disulfiram oral
Tier 1
donepezil hcl
Tier 1
EXELON ORAL CAPSULE
Tier 3
EXELON ORAL SOLUTION
Tier 2
EXELON TRANSDERMAL
Tier 2
EXTAVIA
Tier 3
PA
fluoxetine hcl (pmdd)
Tier 1
QL
galantamine hydrobromide
Tier 1
galantamine hydrobromide er
Tier 1
GILENYA
Tier 3
PA; QL
GRALISE ORAL TABLET 300 MG, 600 MG
Tier 3
PA; ST; N1; QL
GRALISE STARTER
Tier 3
PA; ST; QL
LEMTRADA
Tier 3
PA; ST; QL
NAMENDA
Tier 2
#
NAMENDA TITRATION PAK
Tier 2
#
NAMENDA XR
Tier 2
#
NAMENDA XR TITRATION PACK
Tier 2
#
NAMZARIC
Tier 2
NICODERM CQ
CE
QL
nicotine
CE
QL
nicotine polacrilex mouth/throat
CE
QL
NICOTROL
CE
NICOTROL NS
CE
NUEDEXTA
Tier 3
PA; QL
olanzapine-fluoxetine hcl
Tier 1
QL
(Updated 07/01/15)
136
Drug Name
Drug Status
Drug Details
ORAP
Tier 3
PLEGRIDY
Tier 3
PA; ST; QL
PLEGRIDY STARTER PACK
Tier 3
PA; ST; QL
RAZADYNE
Tier 3
RAZADYNE ER
Tier 3
REBIF
Tier 2
PA
REBIF REBIDOSE
Tier 2
PA
REBIF REBIDOSE TITRATION PACK
Tier 2
PA
REBIF TITRATION PACK
Tier 2
PA
rivastigmine tartrate
Tier 1
SARAFEM
Tier 3
QL
SAVELLA
Tier 3
PA; ST; N1; QL
SAVELLA TITRATION PACK
Tier 2
PA; ST; QL
SYMBYAX
Tier 3
QL
TECFIDERA
Tier 3
PA; ST; N1
TYSABRI
Tier 3
PA
XENAZINE ORAL TABLET 12.5 MG, 25 MG
Tier 2
PA; #; QL
XYREM
Tier 3
PA; QL
ARALAST NP
Tier 3
PA
CUROSURF
Tier 3
ESBRIET
Tier 3
PA; QL
GLASSIA
Tier 3
PA
INFASURF
Tier 3
KALYDECO
Tier 3
PA; QL
OFEV
Tier 3
PA; QL
PROLASTIN
Tier 3
PA
PROLASTIN-C
Tier 3
PA
PULMOZYME
Tier 2
PA
SCLEROSOL INTRAPLEURAL
Tier 3
STERILE TALC POWDER
Tier 3
ZEMAIRA
Tier 3
PA
ACTICLATE
Tier 3
PA; ST
ADOXA
Tier 3
PA
ADOXA PAK 1/100
Tier 3
PA
ADOXA PAK 1/150
Tier 3
PA
ADOXA PAK 2/100
Tier 3
PA
*RESPIRATORY AGENTS - MISC.*
*TETRACYCLINES*
(Updated 07/01/15)
137
Drug Name
Drug Status
Drug Details
avidoxy
Tier 1
PA
demeclocycline hcl oral
Tier 1
PA
DORYX ORAL TABLET DELAYED RELEASE
150 MG, 200 MG
Tier 3
PA
doxycycline hyclate oral capsule
Tier 1
PA; LGC
doxycycline hyclate oral tablet 100 mg
Tier 1
PA; LGC
doxycycline hyclate oral tablet 20 mg
Tier 1
PA
doxycycline hyclate oral tablet delayed release
Tier 1
PA
doxycycline monohydrate
Tier 1
PA
MINOCIN ORAL CAPSULE 100 MG, 50 MG
Tier 3
PA
minocycline hcl er
Tier 1
PA
minocycline hcl oral
Tier 1
PA
MONODOX ORAL CAPSULE 100 MG, 75 MG
Tier 3
PA
MORGIDOX ORAL
Tier 1
PA
NICAZELDOXY 30
Tier 3
NICAZELDOXY 60
Tier 3
SOLODYN
Tier 3
PA
tetracycline hcl oral
Tier 1
LGC
VIBRAMYCIN
Tier 3
PA
*THYROID AGENTS*
ARMOUR THYROID ORAL TABLET 120 MG,
15 MG, 180 MG, 240 MG, 300 MG
Tier 3
CYTOMEL
Tier 3
LEVOTHROID
Tier 1
levothyroxine sodium oral tablet 100 mcg, 112 mcg,
125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25
mcg, 50 mcg, 75 mcg, 88 mcg
Tier 1
levothyroxine sodium oral tablet 300 mcg
Tier 1
LEVOXYL
Tier 1
liothyronine sodium oral
Tier 1
methimazole oral
Tier 1
NATURE-THROID
Tier 3
np thyroid
Tier 1
propylthiouracil oral
Tier 1
SYNTHROID
Tier 3
TAPAZOLE
Tier 3
THYROLAR-1
Tier 3
THYROLAR-1/2
Tier 3
THYROLAR-1/4
Tier 3
LGC
(Updated 07/01/15)
138
Drug Name
Drug Status
THYROLAR-2
Tier 3
THYROLAR-3
Tier 3
TIROSINT
Tier 3
UNITHROID
Tier 1
UNITHROID DIRECT
Tier 1
WESTHROID
Tier 3
WESTHROID-P
Tier 3
WP THYROID ORAL TABLET 113.75 MG, 130
MG, 16.25 MG, 32.5 MG, 48.75 MG, 65 MG, 97.5
MG
Tier 3
Drug Details
*ULCER DRUGS*
acid reducer maximum strength oral tablet 20 mg
Tier 1
LGC
ACIPHEX
Tier 3
PA; ST; N1; QL
ACIPHEX SPRINKLE
Tier 3
ST; N1; QL
amoxicill-clarithro-lansopraz
Tier 1
AXID ORAL CAPSULE 300 MG
Tier 3
AXID ORAL SOLUTION
Tier 3
BENTYL ORAL CAPSULE
Tier 3
BENTYL ORAL TABLET
Tier 3
CANTIL
Tier 3
CARAFATE
Tier 3
chlordiazepoxide-clidinium
Tier 1
cimetidine hcl oral
Tier 1
cimetidine oral tablet 300 mg, 400 mg
Tier 1
cimetidine oral tablet 800 mg
Tier 1
colidrops
Tier 1
CUVPOSA
Tier 3
CYTOTEC
Tier 3
DEXILANT
Tier 2
QL
dicyclomine hcl oral capsule
Tier 1
LGC
dicyclomine hcl oral tablet
Tier 1
LGC
DONNATAL
Tier 3
DONNATAL EXTENTABS
Tier 3
ed-spaz
Tier 1
esomeprazole magnesium oral capsule delayed
release 40 mg
Tier 1
QL
esomeprazole strontium oral capsule delayed release
49.3 mg
Tier 3
PA; ST; N1; QL
famotidine oral suspension reconstituted
Tier 1
LGC
(Updated 07/01/15)
139
Drug Name
Drug Status
Drug Details
famotidine oral tablet 40 mg
Tier 1
LGC
GASTRINEX NF
Tier 3
GLYCATE
Tier 3
glycopyrrolate oral
Tier 1
HYOMAX-SL
Tier 1
hyoscyamine sulfate er
Tier 1
hyoscyamine sulfate oral
Tier 1
hyoscyamine sulfate sublingual
Tier 1
hyosyne
Tier 1
kp omeprazole magnesium
Tier 1
LGC
lansoprazole oral capsule delayed release 30 mg
Tier 1
QL
methscopolamine bromide oral
Tier 1
misoprostol oral
Tier 1
NEXIUM
Tier 2
nizatidine
Tier 1
NULEV
Tier 1
OMECLAMOX-PAK
Tier 3
omeprazole oral capsule delayed release 10 mg, 40
mg
Tier 1
QL
omeprazole oral capsule delayed release 20 mg
Tier 1
LGC; QL
omeprazole-sodium bicarbonate oral capsule 40-1100
mg
Tier 1
QL
oscimin
Tier 1
oscimin sr
Tier 1
PAMINE
Tier 3
PAMINE FORTE
Tier 3
pantoprazole sodium oral
Tier 1
PEPCID ORAL SUSPENSION
RECONSTITUTED
Tier 3
PEPCID ORAL TABLET 40 MG
Tier 3
PREVACID ORAL CAPSULE DELAYED
RELEASE 30 MG
Tier 3
PA; ST; N1; QL
PREVACID SOLUTAB
Tier 3
PA; ST; N1; QL
PREVPAC
Tier 3
N1
PRILOSEC ORAL CAPSULE DELAYED
RELEASE
Tier 3
PA; ST; N1; QL
PRILOSEC ORAL PACKET
Tier 3
PA; ST; N1; QL
PRILOSEC OTC
Tier 1
LGC
PROTONIX ORAL
Tier 3
PA; ST; N1; QL
ST; N1
#; QL
QL
PYLERA
Tier 3
(Updated 07/01/15)
140
Drug Name
Drug Status
Drug Details
rabeprazole sodium
Tier 1
QL
ranitidine hcl oral capsule 300 mg
Tier 1
ranitidine hcl oral syrup
Tier 1
ranitidine hcl oral tablet 300 mg
Tier 1
ROBINUL ORAL
Tier 3
ROBINUL-FORTE
Tier 3
sucralfate oral tablet
Tier 1
SYMAX DUOTAB
Tier 3
SYMAX FASTABS
Tier 1
SYMAX-SL
Tier 1
SYMAX-SR
Tier 1
ZEGERID ORAL CAPSULE 40-1100 MG
Tier 3
PA; ST; N1; QL
ZEGERID ORAL PACKET
Tier 3
PA; ST; N1; QL
LGC
*URINARY ANTI-INFECTIVES*
FURADANTIN
Tier 3
HIPREX
Tier 3
HYOPHEN
Tier 1
MACROBID
Tier 3
MACRODANTIN
Tier 3
methenamine hippurate
Tier 1
methenamine mandelate oral tablet 1 gm
Tier 1
MONUROL
Tier 3
nitrofurantoin
Tier 1
nitrofurantoin macrocrystal oral
Tier 1
nitrofurantoin monohyd macro
Tier 1
PHOSPHASAL
Tier 1
ur n-c
Tier 1
URELLE
Tier 3
UREX
Tier 3
URIBEL
Tier 3
URIMAR-T
Tier 3
urin ds
Tier 1
UROQID #2
Tier 3
URYL
Tier 1
USTELL
Tier 1
UTA
Tier 1
uticap
Tier 1
UTIRA-C
Tier 1
(Updated 07/01/15)
141
Drug Name
UTRONA-C
Drug Status
Drug Details
Tier 1
*URINARY ANTISPASMODICS*
bethanechol chloride oral tablet 25 mg
Tier 1
DETROL LA
Tier 3
ST; N1; QL
DITROPAN XL ORAL TABLET EXTENDED
Tier 3
ST; N1; QL
MYRBETRIQ
Tier 2
ST; N1; QL
oxybutynin chloride er
Tier 1
QL
oxybutynin chloride oral tablet
Tier 1
LGC
OXYTROL
Tier 3
PA; ST
SANCTURA
Tier 3
ST; N1; QL
tolterodine tartrate er
Tier 1
QL
trospium chloride
Tier 1
QL
trospium chloride er
Tier 1
QL
VESICARE
Tier 2
ST; N1; QL
*VAGINAL PRODUCTS*
AVC VAGINAL
Tier 3
CLEOCIN VAGINAL
Tier 3
clindamycin phosphate vaginal
Tier 1
CLINDESSE
Tier 3
CRINONE
Tier 2
ENCARE VAGINAL SUPPOSITORY
Tier 3
ENDOMETRIN
Tier 2
ESTRACE VAGINAL
Tier 3
ESTRING
Tier 3
FEM PH
Tier 3
FEMRING
Tier 3
FIRST-PROGESTERONE VGS 100
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
GYNAZOLE-1
Tier 3
GYNOL II
Tier 3
PA; QL
GYNOL II EXTRA STRENGTH
Tier 3
PA
METROGEL-VAGINAL
Tier 3
metronidazole vaginal
Tier 1
NUVESSA
Tier 3
PA
#; QL
OPTIONS CONCEPTROL
Tier 3
PA
(Updated 07/01/15)
142
Drug Name
Drug Status
OPTIONS GYNOL II CONTRACEPTIVE
Tier 3
PREMARIN VAGINAL
Tier 2
RELAGARD
Tier 3
SHUR-SEAL CONTRACEPTIVE
Tier 3
TERAZOL 3
Tier 3
TERAZOL 7
Tier 3
terconazole
Tier 1
TODAY SPONGE
CE
VAGIFEM
Tier 3
VANDAZOLE
Tier 1
VCF VAGINAL CONTRACEPTIVE VAGINAL
FILM
CE
VCF VAGINAL CONTRACEPTIVE VAGINAL
FOAM
Tier 3
ZAZOLE
Tier 1
Drug Details
PA
PA
QL
PA
*VASOPRESSORS*
ADRENACLICK
Tier 3
PA; ST; N1; QL
AUVI-Q
Tier 2
QL
EPIPEN 2-PAK
Tier 2
N1; QL
EPIPEN JR
Tier 2
QL
EPIPEN JR 2-PAK
Tier 2
N1; #; QL
midodrine hcl
Tier 1
NORTHERA ORAL CAPSULE 100 MG, 200
MG, 300 MG
Tier 3
PA; ST; QL
TWINJECT
Tier 3
QL
*VITAMINS*
delta d3
DRISDOL ORAL CAPSULE
CE
Tier 3
D-VI-SOL
CE
D-VITA
CE
ENDUR-ACIN
Tier 1
eql niacin
Tier 1
ergocalciferol oral capsule
Tier 1
gnp niacin
Tier 1
gnp niacin tr
Tier 1
hm niacin
Tier 1
MEPHYTON
Tier 2
niacin er oral capsule extended release*
Tier 1
(Updated 07/01/15)
143
Drug Name
Drug Status
niacin er oral tablet extendedrelease* 250 mg, 500
mg, 750 mg
Tier 1
niacin oral tablet
Tier 1
niacin-50
Tier 1
POTABA
Tier 3
px niacin
Tier 1
ra niacin
Tier 1
ra no flush niacin
Tier 1
SLO-NIACIN ORAL TABLET
EXTENDEDRELEASE* 250 MG
Tier 1
SLO-NIACIN ORAL TABLET
EXTENDEDRELEASE* 500 MG, 750 MG
Tier 3
sm niacin cr
Tier 1
vitamin d (ergocalciferol)
Tier 1
vitamin d2 oral tablet 400 unit
CE
vitamin d3 oral capsule 1000 unit, 400 unit
CE
vitamin d3 oral liquid† 400 unit/ml
CE
vitamin d3 oral tablet 1000 unit, 400 unit
CE
vitamin d3 oral tablet chewable 400 unit
CE
Drug Details
(Updated 07/01/15)
144
Index
Index
Index
ACCU-CHEK SOFTCLIX
ACURA CONTROL ................................ 91
LANCET DEV ................................................. 90 ACUVAIL ........................................................... 128
ACCU-CHEK SOFTCLIX
acyclovir ........................................................... 41, 56
LANCETS .............................................................. 90 ACZONE ................................................................. 56
ACCUPRIL .......................................................... 30 ADAGEN ............................................................... 46
ACCURETIC ..................................................... 30 ADALAT CC ..................................................... 46
ACCUTREND GLUCOSE .............. 68 adapalene ................................................................... 56
ACCUTREND GLUCOSE
ADAPTER PED DISPOSABLE
CONTROL ............................................................ 90 ................................................................................................ 91
acd formula a ......................................................... 17 ADCIRCA .............................................................. 47
acd formula b ......................................................... 17 ADDERALL .......................................................... 3
acd-a ................................................................................ 17 ADDERALL XR .............................................. 3
ACD-A NOCLOT-50 ............................... 17 adefovir dipivoxil .............................................. 41
ACE AEROSOL CLOUD
ADEMPAS ............................................................ 47
ENHANCER ...................................................... 91 adjustable lancing device .......................... 91
acebutolol hcl ........................................................ 45 ADOXA ................................................................. 137
ACEON ...................................................................... 30 ADOXA PAK 1/100 ................................ 137
acetaminophen-codeine ................................. 8 ADOXA PAK 1/150 ................................ 137
acetaminophen-codeine #2 ........................ 8 ADOXA PAK 2/100 ................................ 137
acetaminophen-codeine #3 ........................ 8 ADRENACLICK ...................................... 143
acetaminophen-codeine #4 ........................ 8 ADRENALIN ................................................ 127
ACETASOL HC .......................................... 133 adult aerosol mask ........................................... 91
acetazolamide ....................................................... 75 adult mask ................................................................ 91
acetazolamide er ................................................ 75 adult mask large ................................................. 91
ACETEST ............................................................... 68 ADVAIR DISKUS ...................................... 15
acetic acid .................................................... 82, 133 ADVAIR HFA ................................................. 15
acetylcysteine ........................................................ 54 ADVANCE INTUITION
acid reducer maximum strength ... 139 CONTROL ............................................................ 91
ACIPHEX ............................................................ 139 ADVANCE INTUITION TEST
ACIPHEX SPRINKLE ...................... 139 ................................................................................................ 68
acitretin ........................................................................ 56 ADVANCE MICRO-DRAW
ACLOVATE ........................................................ 56 CONTROL ............................................................ 91
ACTEMRA .............................................................. 5 ADVANCE MICRO-DRAW
ACTHAR HP ..................................................... 76 NORMAL ............................................................... 91
ACTICIN ................................................................. 56 ADVANCE MICRO-DRAW
ACTICLATE ................................................... 137 TEST .............................................................................. 68
ACTIGALL .......................................................... 80 advanced am/pm ............................................. 119
acti-lance 28g ........................................................ 91 ADVATE ................................................................. 83
acti-lance lite lancets 28g ........................ 91 ADVICOR .............................................................. 29
acti-lance special lancets 17g .............. 91 ADVOCATE CONTROL
acti-lance universal 23g ............................. 91 SOLUTION .......................................................... 91
ACTIMMUNE ................................................. 36 ADVOCATE INSULIN PEN
ACTIQ ............................................................................ 8 NEEDLES .............................................................. 91
active fe ........................................................................ 85 ADVOCATE INSULIN
active ob ................................................................... 119 SYRINGE ............................................................... 91
ACTIVELLA ...................................................... 79 ADVOCATE LANCETS ..................... 91
active-medicated spec collect ............... 68 ADVOCATE LANCING DEVICE
ACTIVITY POUCH .................................. 91 ................................................................................................ 91
ACTONEL ............................................................. 76 ADVOCATE RAPID-SAFE
ACTOPLUS MET ........................................ 22 LANCING ............................................................. 91
ACTOPLUS MET XR ............................ 22 ADVOCATE REDI-CODE ............. 68
ACTOS ........................................................................ 22 ADVOCATE REDI-CODE+
ACULAR ............................................................. 128 CONTROL ............................................................ 91
ACULAR LS ................................................... 128 ADVOCATE REDI-CODE+
ACURA BLOOD GLUCOSE
TEST .............................................................................. 68
TEST .............................................................................. 68
(Updated 07/01/15)
Index
1st choice lancets super thin ................. 90
1st choice lancets thin .................................. 90
1st choice lancets ultra thin ................... 90
1st choice pen needles .................................. 90
1st tier unifine pentips ................................. 90
1st tier unifine pentips plus .................... 90
1st tier unilet comfortouch ..................... 90
8-MOP ......................................................................... 56
a/b otic ....................................................................... 133
abacavir sulfate ................................................... 41
abacavir-lamivudine-zidovudine ....... 41
ABILIFY .................................................................. 39
ABILIFY DISCMELT ........................... 39
ABILIFY MAINTENA ........................ 39
ABSORICA ........................................................... 56
ABSTRAL .................................................................. 8
acamprosate calcium ................................. 135
ACANYA ................................................................ 56
acarbose ...................................................................... 22
ACCOLATE ........................................................ 15
ACCU-CHEK ACTIVE ........................ 67
ACCU-CHEK ACTIVE
GLUCOSE CONT ....................................... 90
ACCU-CHEK AVIVA ................. 67, 90
ACCU-CHEK AVIVA PLUS ........ 67
ACCU-CHEK COMFORT
CURVE ............................................................ 67, 90
ACCU-CHEK COMFORT
CURVE LINEAR ......................................... 90
ACCU-CHEK COMPACT ............... 67
ACCU-CHEK COMPACT BLUE
CONTROL ............................................................ 90
................................................................................................ 68
CONTROL ............................................................ 90
ACCU-CHEK COMPACT TEST
DRUM ........................................................................ 68
ACCU-CHEK FASTCLIX
LANCET .................................................................. 90
ACCU-CHEK FASTCLIX
LANCETS .............................................................. 90
ACCU-CHEK INSTANT
CONTROL ............................................................ 90
ACCU-CHEK MULTICLIX
LANCET DEV ................................................. 90
ACCU-CHEK MULTICLIX
LANCETS .............................................................. 90
ACCU-CHEK SAFE-T PRO
LANCETS .............................................................. 90
ACCU-CHEK SMARTVIEW ...... 68
ACCU-CHEK SMARTVIEW
CONTROL ............................................................ 90
ACCU-CHEK SOFT TOUCH
LANCETS .............................................................. 90
145
ALTAFLUOR ............................................... 128
ALTAFRIN ...................................................... 128
ALTAVERA ........................................................ 48
alternate site lancing device .................. 92
ALTOPREV ......................................................... 29
ALUVEA ................................................................. 57
ALVESCO .............................................................. 15
alyacen 1/35 ............................................................ 48
alyacen 7/7/7 .......................................................... 48
amantadine hcl ..................................................... 38
AMARYL ............................................................... 22
AMBIEN .................................................................. 88
AMBIEN CR ...................................................... 88
amcinonide ............................................................... 57
AMERGE ............................................................ 115
AMETHIA ............................................................. 49
AMETHIA LO ................................................. 49
AMICAR ................................................................. 88
amiloride hcl ........................................................... 75
amiloride-hydrochlorothiazide ........... 75
aminoacetic acid ................................................ 82
aminocaproic acid ............................................ 88
amiodarone hcl .................................................... 14
AMITIZA ................................................................ 80
amitriptyline hcl ................................................. 20
amlodipine besy-benazepril hcl .......... 30
amlodipine besylate ........................................ 46
amlodipine besylate-valsartan ............ 30
amlodipine-valsartan-hctz ....................... 30
AMMONUL ........................................................ 76
AMNESTEEM ................................................. 57
amoxicill-clarithro-lansopraz .......... 139
amoxicillin ............................................................ 135
amoxicillin-pot clavulanate ................ 135
amoxicillin-pot clavulanate er ......... 135
amphetamine-dextroamphet er ............. 3
amphetamine-dextroamphetamine ... 3
ampicillin ................................................................ 135
AMPYRA ............................................................ 135
AMRIX ................................................................... 126
AMTURNIDE .................................................. 31
ANACAINE ........................................................ 57
ANADROL-50 .................................................. 11
ANAFRANIL ................................................... 20
anagrelide hcl ........................................................ 84
ANALPRAM-HC ......................................... 12
ANAPROX ............................................................... 5
ANAPROX DS .................................................... 5
anastrozole ............................................................... 36
ANDROGEL ...................................................... 12
ANDROGEL PUMP ................................ 11
ANDROID ............................................................ 12
ANDROXY .......................................................... 12
ANGELIQ .............................................................. 79
ANIMI-3 ................................................................... 85
ANIMI-3/VITAMIN D .......................... 85
anolor 300 ..................................................................... 7
ANORO ELLIPTA ..................................... 15
Index
AIRZONE PEAK FLOW METER
................................................................................................ 92
AKNE-MYCIN ............................................... 56
AK-PENTOLATE .................................... 128
ak-poly-bac ........................................................... 128
AKTEN .................................................................. 128
AKYNZEO ........................................................... 27
ala quin ......................................................................... 56
ALAGESIC LQ ................................................... 7
ALBAFORT ........................................................ 85
albatussin ................................................................... 54
albatussin nn ........................................................... 54
ALBENZA ............................................................. 13
albertsons test ....................................................... 68
ALBUSTIX ........................................................... 68
albuterol sulfate .................................................. 15
albuterol sulfate er .......................................... 15
ALCAINE ........................................................... 128
alclometasone dipropionate ................... 56
ALCOH-GLOVE CONTOURED
WIPE ............................................................................. 92
alcohol pads ............................................................ 92
alcohol prep ............................................................. 92
alcohol prep pad ................................................. 92
alcohol preps .......................................................... 92
alcohol swabs ......................................................... 92
alcohol wipes .......................................................... 92
ALCORTIN A .................................................. 56
ALDACTAZIDE ........................................... 75
ALDACTONE .................................................. 75
ALDARA ................................................................ 56
ALDURAZYME ........................................... 76
alendronate sodium ......................................... 76
ALFERON N ..................................................... 36
alfuzosin hcl er ..................................................... 82
ALICLEN ............................................................... 56
ALINIA ..................................................................... 34
ALKERAN ........................................................... 36
ALL FLOW 1000 PFT FILTER
................................................................................................ 92
allopurinol ................................................................. 83
ALOCRIL ............................................................ 128
ALOMIDE ......................................................... 128
ALOQUIN ............................................................. 57
ALORA ...................................................................... 79
ALPHAGAN P ............................................. 128
ALPHANATE/VWF
COMPLEX/HUMAN ............................. 83
ALPHANINE SD ......................................... 83
alphatrex .................................................................... 57
alprazolam ................................................................ 14
alprazolam er ........................................................ 14
ALPRAZOLAM INTENSOL ....... 14
alprazolam xr ........................................................ 14
ALREX ................................................................... 128
ALTABAX ............................................................. 57
ALTACAINE ................................................. 128
ALTACE .................................................................. 30
Index
Index
ADVOCATE SAFETY LANCETS
................................................................................................ 91
ADVOCATE TEST .................................... 68
AERO OTIC HC ......................................... 133
AEROCHAMBER MINI
CHAMBER .......................................................... 91
AEROCHAMBER MV ......................... 91
AEROCHAMBER PLUS ................... 91
................................................................................................ 91
LARGE ...................................................................... 91
MEDIUM ............................................................... 91
SMALL ...................................................................... 91
W/MASK ................................................................. 91
AEROCHAMBER PLUS FLOW
VU ..................................................................................... 91
AEROCHAMBER PLUS
W/MASK ................................................................. 91
AEROCHAMBER PLUS
W/MASK SMALL ....................................... 91
AEROCHAMBER
W/FLOWSIGNAL ...................................... 91
................................................................................................ 91
CHAMBR ............................................................... 91
AEROCHAMBER Z-STAT
PLUS/LARGE .................................................. 91
AEROCHAMBER Z-STAT
PLUS/MEDIUM ............................................ 92
AEROCHAMBER Z-STAT
PLUS/SMALL ................................................... 92
AEROSPAN ........................................................ 15
AEROTRACH PLUS .............................. 92
af lancets super thin ....................................... 92
AFEDITAB CR ............................................... 46
AFINITOR ............................................................ 36
AFINITOR DISPERZ ............................ 36
AFREZZA ............................................................. 22
AGAMATRIX AMP TEST ............. 68
AGAMATRIX CONTROL ............. 92
AGAMATRIX JAZZ TEST ............ 68
AGAMATRIX KEYNOTE TEST
................................................................................................ 68
AGAMATRIX PRESTO TEST
................................................................................................ 68
AGAMATRIX ULTRA-THIN
LANCETS .............................................................. 92
AGGRENOX ..................................................... 83
AGRYLIN ............................................................. 83
aif #2 drug preparation kit .................... 56
AIRAVITE ............................................................ 85
AIRS PEDIATRIC AEROSOL
MASK .......................................................................... 92
(Updated 07/01/15)
146
AT LAST TEST ............................................... 68
ATABEX ............................................................... 119
ATABEX EC ................................................... 119
ATACAND ........................................................... 31
ATACAND HCT .......................................... 31
ATELVIA ................................................................ 76
atenolol ......................................................................... 45
atenolol-chlorthalidone .............................. 31
ATGAM .................................................................... 44
ATIVAN ................................................................... 14
atorvastatin calcium ...................................... 29
atovaquone-proguanil hcl ......................... 35
ATRALIN .............................................................. 57
ATRIPLA ................................................................ 41
atropine sulfate ................................................ 128
atropine-care ...................................................... 128
ATROVENT .................................................... 127
ATROVENT HFA ...................................... 15
AUBAGIO .......................................................... 136
AUBRA ..................................................................... 49
AUGMENTIN .............................................. 135
AUGMENTIN ES-600 ........................ 135
AUGMENTIN XR .................................. 135
aurax ........................................................................... 133
AURODEX ....................................................... 133
AUROGUARD ........................................... 133
AURORA HEALTHCARE
LANCETS .............................................................. 93
aurora lancet super thin 30g ................. 93
aurora lancet thin 23g ................................. 93
aurora pen needles ........................................... 93
aurora unifine pentips .................................. 93
auroto ......................................................................... 133
AURYXIA ............................................................. 80
AUTOJECT 2 ..................................................... 93
AUTO-LANCET ........................................... 93
AUTO-LANCET MINI ........................ 93
AUTOLET II CLINISAFE .............. 93
AUTOLET IMPRESSION ............... 93
AUTOLET LANCING DEVICE
................................................................................................ 93
AUTOLET LITE CLINISAFE ... 93
AUTOLET LITE STARTER
PACK ........................................................................... 93
AUTOLET MINI .......................................... 93
AUTOLET PLATFORMS ................ 93
AUVI-Q .................................................................. 143
AVALIDE ............................................................... 31
AVANDAMET ................................................ 22
AVANDARYL ................................................ 22
AVANDIA ............................................................. 22
AVAPRO ................................................................. 31
AVAR ........................................................................... 57
AVAR CLEANSER ................................... 57
AVAR LS ................................................................. 57
AVAR LS CLEANSER ......................... 57
AVAR-E EMOLLIENT ....................... 57
AVAR-E GREEN ......................................... 57
Index
ASMANEX 120 METERED
DOSES ........................................................................ 15
ASMANEX 14 METERED
DOSES ........................................................................ 15
ASMANEX 30 METERED
DOSES ........................................................................ 15
ASMANEX 60 METERED
DOSES ........................................................................ 15
................................................................................................ 15
ASMANEX HFA .......................................... 15
aspirin ............................................................................... 7
ASSESS FULL RANGE PEAK
METER ...................................................................... 92
ASSESS LOW RANGE PEAK
METER ...................................................................... 92
ASSESS PEAK FLOW METER
................................................................................................ 92
ASSURE 3 CONTROL ......................... 92
ASSURE 3 TEST ........................................... 68
ASSURE 4 CONTROL LEVEL 1
& 2 ..................................................................................... 92
ASSURE 4 TEST ........................................... 68
assure comfort lancets 28g ..................... 92
assure comfort lancets 30g ..................... 92
ASSURE DOSE CONTROL .......... 92
ASSURE DOSE NORM/HIGH
CONTROL ............................................................ 92
ASSURE HAEMOLANCE PLUS
HIGH ............................................................................ 92
LOW ............................................................................... 92
MICRO ...................................................................... 92
NORMAL ............................................................... 92
PED ................................................................................. 92
ASSURE ID INSULIN SAFETY
SYR ................................................................................. 92
ASSURE II ............................................................ 68
ASSURE II CHECK ................................. 68
ASSURE II CONTROL ....................... 92
ASSURE II CONTROL LEVEL 1
& 2 ..................................................................................... 92
ASSURE LANCE LANCETS ...... 93
ASSURE LANCETS ................................ 93
ASSURE PLATINUM ........................... 68
ASSURE PRO CONTROL
LEVEL 1 & 2 ....................................................... 93
ASSURE PRO TEST ................................ 68
ASTAGRAF XL ............................................ 44
ASTEPRO ........................................................... 127
ASTHMA CHECK
METER-ZONE SYSTEM ................. 93
ASTHMAMENTOR ................................ 93
AT LAST CONTROL ............................. 93
AT LAST LANCETS ............................... 93
Index
Index
ANTABUSE ..................................................... 135
ANTARA ................................................................ 29
antibiotic ear ....................................................... 133
anticoagulant cit dext soln a ................ 17
ANTICOAGULANT
COMPOUND .................................................... 17
antifungal ................................................................... 57
antipyrine-benzocaine .............................. 133
anucort-hc ................................................................. 12
ANUSOL-HC ..................................................... 12
ANZEMET ............................................................ 27
APETIMAR/IRON ................................. 119
APEXICON .......................................................... 57
APEXICON E .................................................... 57
APIDRA ................................................................... 22
APIDRA SOLOSTAR ............................ 22
APLENZIN ........................................................... 20
apraclonidine hcl ............................................ 128
APRI .............................................................................. 49
APRISO ..................................................................... 80
APTENSIO XR ................................................... 3
APTIOM ................................................................... 17
APTIVUS ................................................................ 41
aqua lance adjustable lancing ............. 92
AQUORAL ........................................................ 118
ARALAST NP ............................................... 137
ARALEN ................................................................. 35
ARANELLE ........................................................ 49
ARANESP (ALBUMIN FREE)
................................................................................................ 85
ARBINOXA ........................................................ 28
ARCALYST ............................................................ 5
ARCAPTA NEOHALER ................... 15
ARGYLE STERILE SALINE ...... 82
ARGYLE STERILE WATER ...... 44
ARIAL CHAMBER .................................. 92
ARICEPT ............................................................. 135
ARICEPT ODT ............................................ 135
ARIDOL ................................................................... 68
ARIMIDEX ......................................................... 36
aripiprazole .............................................................. 39
ARIXTRA .............................................................. 17
ARMOUR THYROID ....................... 138
ARNUITY ELLIPTA .............................. 15
AROMASIN ........................................................ 36
ARTHROTEC ...................................................... 5
ARTISS ...................................................................... 88
ASACOL HD ..................................................... 80
ASCENSIA AUTODISC
CONTROL ............................................................ 92
ASCENSIA AUTODISC
CONTROLS ........................................................ 92
ASCENSIA AUTODISC TEST
................................................................................................ 68
ASCOMP-CODEINE .................................. 8
ASMALPRED .................................................. 53
ASMALPRED PLUS ............................... 53
(Updated 07/01/15)
147
benzoyl peroxide short contact .......... 57
benzoyl peroxide-erythromycin ........ 57
benztropine mesylate .................................... 38
BEPREVE ........................................................... 128
BERINERT .......................................................... 84
BESIVANCE ................................................... 128
BETADINE OPHTHALMIC
PREP .......................................................................... 128
BETAGAN ......................................................... 128
betamethasone dipropionate ................. 57
betamethasone dipropionate aug ..... 57
betamethasone valerate .............................. 57
BETAPACE .......................................................... 45
BETAPACE AF .............................................. 45
BETASERON ................................................. 136
betaxolol hcl ............................................. 45, 128
bethanechol chloride .................................. 142
BETHKIS ................................................................... 5
BETIMOL ........................................................... 128
BETOPTIC-S ................................................... 129
BEYAZ ....................................................................... 49
BG STAR TEST .............................................. 68
BIAXIN ..................................................................... 89
BIAXIN XL .......................................................... 89
BIAXIN XL PAC .......................................... 89
bicalutamide ........................................................... 36
BIDIL ........................................................................... 47
BIFERARX .......................................................... 85
BILTRICIDE ...................................................... 13
bimatoprost .......................................................... 129
BINOSTO ................................................................ 76
BIO GLO .............................................................. 129
BIOSCANNER GLUCOSE TEST
................................................................................................ 68
bio-statin ..................................................................... 27
bisoprolol fumarate ........................................ 45
bisoprolol-hydrochlorothiazide .......... 31
bl test strip pack ................................................. 68
BLEPHAMIDE ............................................ 129
BLEPHAMIDE S.O.P. ........................ 129
blood glucose test .............................................. 68
B-NEXA ................................................................ 119
BONIVA ................................................................... 76
BOSULIF ................................................................ 36
BOTOX ................................................................... 128
BOTOX COSMETIC ................................ 57
bp 10-1 .......................................................................... 57
bp cleansing wash ............................................. 57
bp foam ........................................................................ 58
bp vit 3 ........................................................................... 85
bpo ..................................................................................... 58
bpo foaming cloths .......................................... 58
BREATHERITE ............................................ 94
BREATHERITE COLL SPACER
ADULT ...................................................................... 94
CHILD ........................................................................ 94
Index
BD INSULIN SYR ULTRAFINE
II .......................................................................................... 93
BD INSULIN SYRINGE ................... 93
BD INSULIN SYRINGE
HALF-UNIT ....................................................... 93
BD INSULIN SYRINGE
MICROFINE ........................................... 93, 94
BD INSULIN SYRINGE U-40 ... 94
BD INSULIN SYRINGE
ULTRAFINE ..................................................... 94
BD INTEGRA INSULIN
SYRINGE ............................................................... 94
BD INTEGRA SYRINGE ................ 94
BD LANCET DEVICE .......................... 94
................................................................................................ 94
................................................................................................ 94
BD MICROTAINER LANCETS
................................................................................................ 94
BD PEN NEEDLE MINI U/F ..... 94
BD PEN NEEDLE NANO U/F
................................................................................................ 94
BD PEN NEEDLE SHORT U/F
................................................................................................ 94
BD PEN NEEDLE ULTRAFINE
................................................................................................ 94
BD SAFETYGLIDE INSULIN
SYRINGE ............................................................... 94
BD SAFETY-LOK INSULIN
SYRINGE ............................................................... 94
BD SWAB SINGLE USE
REGULAR ........................................................... 94
BD SWABS SINGLE USE
BUTTERFLY .................................................... 94
BD TEST .................................................................. 68
BD ULTRA-FINE LANCETS .... 94
BEBULIN ............................................................... 84
BEBULIN VH ................................................... 84
BECONASE AQ ......................................... 127
BELSOMRA ....................................................... 88
benazepril hcl ......................................................... 31
benazepril-hydrochlorothiazide ........ 31
BENEFIX ................................................................ 84
BENICAR ............................................................... 31
BENICAR HCT .............................................. 31
BENLYSTA ......................................................... 44
bensal hp ..................................................................... 57
BENTYL ............................................................... 139
BENZAMYCIN .............................................. 57
BENZAMYCINPAK ............................... 57
BENZEPRO ......................................................... 57
BENZEPRO SHORT CONTACT
................................................................................................ 57
BENZIQ .................................................................... 57
BENZIQ LS .......................................................... 57
benzonatate ............................................................. 54
benzoyl peroxide ................................................ 57
Index
Index
AVAR-E LS .......................................................... 57
AVC VAGINAL .......................................... 142
AVIANE ................................................................... 49
avidoxy ...................................................................... 138
AVINZA ...................................................................... 8
AVITA ......................................................................... 57
AVODART ........................................................... 82
AVONEX ............................................................. 136
AVONEX PEN ............................................. 136
AVONEX PREFILLED ................... 136
AXERT ................................................................... 115
AXID ......................................................................... 139
AXIRON .................................................................. 12
AYGESTIN ....................................................... 135
AZASAN .................................................................. 44
AZASITE ............................................................. 128
azathioprine ............................................................ 44
azelastine hcl ......................................... 127, 128
AZELEX ................................................................... 57
AZILECT ................................................................ 38
azithromycin ........................................................... 89
AZOPT .................................................................... 128
AZOR ........................................................................... 31
AZULFIDINE .................................................. 80
AZULFIDINE EN-TABS .................. 80
AZURETTE ......................................................... 49
bacitracin-polymyxin b ........................... 128
bacitra-neomycin-polymyxin-hc ... 128
baclofen .................................................................... 126
BACTRIM ............................................................. 34
BACTRIM DS .................................................. 34
BACTROBAN .................................................. 57
BACTROBAN NASAL ..................... 127
BAL-CARE DHA ..................................... 119
balsalazide disodium ..................................... 80
BALZIVA ................................................................ 49
BANZEL .................................................................. 17
BARACLUDE .................................................. 41
BAR-TEST ............................................................. 68
BAYCADRON ................................................ 53
BAYER BREEZE 2 CONTROL
................................................................................................ 93
BAYER BREEZE 2 TEST ................. 68
BAYER CONTOUR ................................. 93
BAYER CONTOUR NEXT
CONTROL ............................................................ 93
BAYER CONTOUR NEXT TEST
................................................................................................ 68
BAYER CONTOUR TEST .............. 68
BAYER MICROLET 2
LANCING DEVIC ..................................... 93
BAYER MICROLET LANCETS
................................................................................................ 93
baza antifungal .................................................... 57
BD AUTOSHIELD .................................... 93
BD AUTOSHIELD DUO .................. 93
BD GLUCOSE ................................................. 22
(Updated 07/01/15)
148
careone unifine pentips plus .................. 95
CARESENS CONTROL A .............. 95
CARESENS N GLUCOSE TEST
................................................................................................ 68
CARIMUNE NF ........................................ 134
carisoprodol ......................................................... 126
carisoprodol-aspirin .................................... 126
carisoprodol-aspirin-codeine ............. 126
CARNITOR ......................................................... 76
CARNITOR SF ............................................... 76
CARRINGTON ANTIFUNGAL
................................................................................................ 58
carteolol hcl ......................................................... 129
CARTIA XT ........................................................ 46
carvedilol .................................................................... 45
CASODEX ............................................................. 36
CATAFLAM .......................................................... 5
CATAPRES .......................................................... 31
CATAPRES-TTS-1 ..................................... 31
CATAPRES-TTS-2 ..................................... 31
CATAPRES-TTS-3 ..................................... 31
CAVAN-FOLATE OB ........................ 119
CAVAREST ...................................................... 118
CAVERJECT ...................................................... 47
CAVERJECT IMPULSE .................... 47
CAYSTON ............................................................. 34
CAZIANT ............................................................... 49
CEDAX ...................................................................... 48
cefaclor ......................................................................... 48
cefadroxil ................................................................... 48
cefdinir .......................................................................... 48
cefixime ....................................................................... 48
cefpodoxime proxetil .................................... 48
cefprozil ....................................................................... 48
CEFTIN ..................................................................... 48
cefuroxime axetil .............................................. 48
CELEBREX ............................................................. 5
celecoxib ........................................................................ 5
CELEXA .................................................................. 20
CELLCEPT ........................................................... 44
CELONTIN .......................................................... 17
CEM-UREA ........................................................ 58
CENESTIN ........................................................... 79
CENFOL .................................................................. 85
CENTANY ............................................................ 58
CENTRATEX ................................................... 85
cephalexin ................................................................. 48
CERDELGA ....................................................... 85
CEREZYME ....................................................... 85
CERISA WASH .............................................. 58
CEROVEL ............................................................. 58
CERVIDIL ......................................................... 134
CESAMET ............................................................. 27
CESIA .......................................................................... 49
cetirizine hcl ............................................................ 28
cetirizine hcl allergy child ....................... 28
CETRAXAL .................................................... 133
cevimeline hcl ..................................................... 118
Index
BYSTOLIC ............................................................ 45
cabergoline ............................................................... 76
CAFCIT ........................................................................ 3
CAFERGOT .................................................... 115
caffeine citrate ......................................................... 3
CALAN ...................................................................... 46
CALAN SR ........................................................... 46
CALCIFOL ....................................................... 116
calcipotriene ........................................................... 58
calcitonin (salmon) ........................................ 76
CALCITRENE ................................................. 58
calcitriol ...................................................................... 76
calcium acetate .................................................... 80
calcium acetate (phos binder) ........... 80
calcium-folic acid plus d ........................ 116
CAMBIA ............................................................... 115
CAMILA .................................................................. 49
CAMPRAL ........................................................ 136
CAMRESE ............................................................ 49
CAMRESE LO ................................................. 49
CANASA ................................................................. 81
candesartan cilexetil ..................................... 31
candesartan cilexetil-hctz ........................ 31
CANTIL ................................................................ 139
CAPACET ................................................................. 7
CAPEX ....................................................................... 58
CAPITAL/CODEINE ................................. 8
CAPRELSA .......................................................... 36
captopril ...................................................................... 31
CARAC ...................................................................... 58
CARAFATE .................................................... 139
CARBAGLU ...................................................... 76
carbamazepine ..................................................... 17
carbamazepine er .............................................. 17
CARBAPHEN 12 .......................................... 54
CARBAPHEN 12 PED .......................... 54
CARBATROL ................................................... 17
carbidopa ................................................................... 38
carbidopa-levodopa ........................................ 38
carbidopa-levodopa er ................................. 38
carbidopa-levodopa-entacapone ....... 38
carbinoxamine maleate .............................. 28
CARDENE SR ................................................. 46
CARDIOCOM LANCING
DEVICE .................................................................... 94
CARDIZEM ........................................................ 46
CARDIZEM CD ............................................ 46
CARDIZEM LA ............................................ 46
CARDURA .......................................................... 31
CARDURA XL ............................................... 82
careone advanced lancing dev ............. 94
CAREONE BLOOD GLUCOSE
TEST .............................................................................. 68
careone lancet thin 23g ............................... 95
careone lancet ultra thin 28g ............... 95
CAREONE ULTIGUARD
INSULIN SYR ................................................. 95
careone unifine pentips ............................... 95
Index
Index
INFANT ................................................................... 94
BREATHERITE RIGID
SPACER/MASK ............................................ 94
BREATHERITE SPACER
NEONATE ............................................................ 94
BREATHERITE SPACER
SMALL CHILD .............................................. 94
BREATHERITE/LARGE MASK
................................................................................................ 94
BREATHERITE/MEDIUM
MASK .......................................................................... 94
BREATHERITE/SMALL MASK
................................................................................................ 94
BREO ELLIPTA ............................................ 15
BREVICON (28) ............................................. 49
briellyn .......................................................................... 49
BRILINTA ............................................................ 84
brimonidine tartrate ................................... 129
BRINTELLIX ................................................... 20
BRISDELLE .................................................... 136
BROMFED DM ............................................. 54
bromocriptine mesylate .............................. 38
BROVANA ........................................................... 15
BUBBLES THE FISH II PEDI
MASK .......................................................................... 94
BUCALSEP .......................................................... 41
BUDEPRION SR .......................................... 20
BUDEPRION XL ......................................... 20
budesonide ................................................... 15, 127
budesonide er ......................................................... 53
bullseye mini safety lancets ................... 94
BULLSEYE SAFETY LANCETS
................................................................................................ 94
bumetanide ............................................................... 75
BUNAVAIL ............................................................ 8
BUPAP ........................................................................... 7
BUPHENYL ........................................................ 76
buprenorphine hcl ................................................. 8
buprenorphine hcl-naloxone hcl ........... 8
BUPROBAN .................................................... 136
bupropion hcl ......................................................... 20
bupropion hcl er (smoking det) .... 136
bupropion hcl er (sr) .................................... 20
bupropion hcl er (xl) .................................... 20
buspirone hcl .......................................................... 14
butalbital compound/codeine ................... 8
butalbital-acetaminophen ........................... 7
butalbital-apap-caff-cod ............................... 8
butalbital-apap-caffeine ................................ 7
butalbital-asa-caff-codeine ........................ 8
butalbital-asa-caffeine .................................... 7
BUTISOL SODIUM ................................. 88
butorphanol tartrate ......................................... 8
BUTRANS ................................................................ 8
BYDUREON ...................................................... 22
BYETTA 10 MCG PEN ....................... 23
BYETTA 5 MCG PEN ........................... 23
(Updated 07/01/15)
149
CLOSERCARE ............................................... 95
clotrimazole ......................................................... 118
clotrimazole-betamethasone ................. 58
clozapine ..................................................................... 39
CLOZARIL .......................................................... 39
c-nate dha ............................................................... 119
CNL8 NAIL ......................................................... 58
co monitor replacement pieces ........... 95
COAGUCHEK LANCETS .............. 95
COARTEM ........................................................... 35
COLAZAL ............................................................. 81
colchicine .................................................................... 83
colchicine-probenecid ................................... 83
COLCRYS ............................................................. 83
COLESTID ............................................................ 29
COLESTID FLAVORED .................. 29
colestipol hcl ........................................................... 29
colidrops .................................................................. 139
colistimethate sodium .................................. 34
COLOCORT ....................................................... 12
COLY-MYCIN M ........................................ 34
COLY-MYCIN S ....................................... 133
COLYTE WITH FLAVOR
PACKS ........................................................................ 89
COMBIGAN ................................................... 129
COMBIPATCH ............................................... 79
COMBISTIX ....................................................... 69
COMBIVENT RESPIMAT ............. 15
COMBIVIR ........................................................... 41
COMETRIQ (100 MG DAILY
DOSE) .......................................................................... 36
DOSE) .......................................................................... 36
DOSE) .......................................................................... 36
comfort assured lancets 28g .................. 95
comfort assured lancets 33g .................. 95
COMFORT EZ INSULIN
SYRINGE ............................................................... 95
COMFORT EZ PEN NEEDLES
................................................................................................ 95
comfort lancets .................................................... 95
COMPAZINE .................................................... 39
COMPLERA ....................................................... 41
completenate ....................................................... 119
complete-rf prenatal ................................... 119
COMPRO ................................................................ 39
COMTAN ............................................................... 38
CO-NATAL FA ........................................... 120
CONCEPT DHA ........................................ 120
CONCEPT OB ............................................... 120
CONCERTA .......................................................... 3
CONDYLOX ...................................................... 58
cone mask .................................................................. 95
constulose .................................................................. 89
control ........................................................................... 95
CONTROL AST ............................................. 69
CONTROL TEST ......................................... 69
Index
CITROLITH ....................................................... 82
CLARAVIS ........................................................... 58
CLARINEX ......................................................... 28
CLARINEX REDITABS .................... 28
CLARINEX-D 12 HOUR .................. 54
CLARINEX-D 24 HOUR .................. 54
CLARIS CLARIFYING WASH
................................................................................................ 58
clarithromycin ...................................................... 89
clarithromycin er ............................................... 89
CLEANLET LANCETS 28G ........ 95
CLEARLAX ........................................................ 89
clemastine fumarate ....................................... 28
CLENIA .................................................................... 58
CLENIA FOAMING WASH ........ 58
CLEOCIN ................................................. 34, 142
CLEOCIN-T ........................................................ 58
CLEVER CHEK AUTO-CODE
TEST .............................................................................. 69
CLEVER CHEK AUTO-CODE
VOICE ......................................................................... 69
CLEVER CHEK LANCETS .......... 95
CLEVER CHEK TEST ......................... 69
CLEVER CHOICE AUTO-CODE
TEST .............................................................................. 69
CLEVER CHOICE GLUCOSE
CONTROL ............................................................ 95
CLEVER CHOICE MICRO TEST
................................................................................................ 69
clickfine pen needles ...................................... 95
CLIMARA ............................................................. 79
CLIMARA PRO ............................................. 79
CLINDACIN ETZ ...................................... 58
CLINDACIN-P ............................................... 58
CLINDAGEL .................................................... 58
CLINDAMAX .................................................. 58
clindamycin hcl .................................................... 34
clindamycin palmitate hcl ....................... 34
clindamycin phos-benzoyl perox ...... 58
clindamycin phosphate .................. 58, 142
CLINDESSE .................................................... 142
CLINISTIX ........................................................... 69
CLINITEST .......................................................... 69
CLINPRO 5000 ............................................ 118
clobetasol propionate ................................... 58
clobetasol propionate e ............................... 58
clobetasol propionate emulsion ......... 58
CLOBEX .................................................................. 58
CLOBEX SPRAY ......................................... 58
CLOMID .................................................................. 76
clomiphene citrate ............................................ 76
clomipramine hcl ............................................... 20
clonazepam .............................................................. 17
clonidine hcl ............................................................ 31
clonidine hcl er ........................................................ 3
clopidogrel bisulfate ....................................... 84
clorazepate dipotassium ............................ 14
CLORPRES .......................................................... 31
Index
Index
CHANTIX .......................................................... 136
CHANTIX CONTINUING
MONTH PAK ................................................ 136
CHANTIX STARTING MONTH
PAK ............................................................................. 136
CHATEAL ............................................................. 49
CHEK-STIX CONTROL ................... 69
CHEMET ................................................................ 26
CHEMSTRIP 10 MD ............................... 69
CHEMSTRIP 10/SG .................................. 69
CHEMSTRIP 2 GP ..................................... 69
CHEMSTRIP 5 OB ..................................... 69
CHEMSTRIP 7 ................................................ 69
CHEMSTRIP 9 ................................................ 69
CHEMSTRIP K .............................................. 69
CHEMSTRIP MICRAL ...................... 69
CHEMSTRIP UGK ................................... 69
CHENODAL ...................................................... 81
cheratussin ac ........................................................ 54
cheratussin dac .................................................... 54
chlordiazepoxide hcl ...................................... 14
chlordiazepoxide-clidinium ................ 139
chlorhexidine gluconate ......................... 118
chloroquine phosphate ................................. 35
chlorothiazide ........................................................ 75
chlorpromazine hcl .......................................... 39
chlorpropamide ................................................... 23
chlorthalidone ....................................................... 75
chlorzoxazone ................................................... 126
CHOICE DM FORA G20 TEST
STRIPS ....................................................................... 69
CHOLBAM .......................................................... 81
cholestyramine ..................................................... 29
cholestyramine light ....................................... 29
choline & mag trisalicylate ........................ 7
choline-mag trisalicylate .............................. 7
CICLODAN ......................................................... 58
ciclopirox ................................................................... 58
ciclopirox olamine ........................................... 58
cidofovir ...................................................................... 41
cilostazol ..................................................................... 84
CILOXAN ........................................................... 129
cimetidine ............................................................... 139
cimetidine hcl ..................................................... 139
CINRYZE ............................................................... 84
CIPRO ......................................................................... 80
CIPRO HC .......................................................... 133
CIPRO XR ............................................................. 80
CIPRODEX ...................................................... 133
ciprofloxacin hcl ................................... 80, 129
ciprofloxacin-ciproflox hcl er ............. 80
citalopram hydrobromide ........................ 20
CITRANATAL 90 DHA .................. 119
CITRANATAL B-CALM ............... 119
CITRANATAL DHA .......................... 119
CITRANATAL HARMONY .... 119
CITRANATAL RX ................................ 119
citric acid-sodium citrate ......................... 82
(Updated 07/01/15)
150
DELZICOL ........................................................... 81
DEMADEX .......................................................... 75
demeclocycline hcl ........................................ 138
DEMEROL .............................................................. 8
DEMSER ................................................................. 31
DENAVIR .............................................................. 59
DENTA 5000 PLUS ................................ 118
DENTAGEL .................................................... 118
dentall 1100 plus ............................................. 118
DEPADE .................................................................. 26
DEPAKENE ........................................................ 17
DEPAKOTE ........................................................ 17
DEPAKOTE ER ............................................ 17
DEPAKOTE SPRINKLES ............... 17
DEPEN TITRATABS ............................. 44
DEPO-PROVERA ....................................... 49
DEPO-SUBQ PROVERA 104 ....... 49
DERMA-SMOOTHE/FS BODY
................................................................................................ 59
DERMA-SMOOTHE/FS SCALP
................................................................................................ 59
DERMASORB AF ...................................... 59
DERMASORB XM .................................... 59
DERMATOP ...................................................... 59
DERMAZENE ................................................. 59
DERMOTIC ..................................................... 133
DESFERAL ......................................................... 26
desipramine hcl .................................................... 20
desloratadine .......................................................... 28
desmopressin ace rhinal tube ............... 77
desmopressin ace spray refrig ............. 77
desmopressin acetate .................................... 77
desmopressin acetate spray ................... 77
DESOGEN ............................................................ 49
desogestrel-ethinyl estradiol ................. 49
DESONATE ........................................................ 59
desonide ....................................................................... 59
DESOWEN ........................................................... 59
desoximetasone ................................................... 59
DESOXYN ............................................................... 3
desvenlafaxine er ............................................... 20
DETROL LA ................................................... 142
DEX4 ............................................................................ 23
DEX4 GLUCOSE ......................................... 23
DEX4 NATURALS ................................... 23
DEX4 POUCH PACK ............................ 23
DEX4 QUICK DISSOLVE
GLUCOSE ............................................................. 23
dexamethasone .................................................... 53
DEXAMETHASONE INTENSOL
................................................................................................ 53
dexamethasone sodium phosphate
............................................................................................. 129
DEXEDRINE ....................................................... 4
DEXILANT ...................................................... 139
dexmethylphenidate hcl ................................. 4
dexmethylphenidate hcl er ......................... 4
DEXPAK 10 DAY ....................................... 53
Index
cvs blood glucose test .................................... 69
cvs glucose ................................................................ 23
cvs glucose bits ..................................................... 23
cvs glucose shot ................................................... 23
cvs insulin syringe ............................................. 95
CVS KETONE CARE ............................. 69
cvs lancets 21g ...................................................... 95
cvs lancets micro thin 33g ....................... 95
cvs lancets original .......................................... 95
cvs lancets thin ..................................................... 95
cvs lancets thin 26g ......................................... 95
cvs lancets ultra thin 30g .......................... 95
cvs lancing device .............................................. 96
cvs ultra thin lancets ...................................... 96
CYCLAFEM 1/35 ......................................... 49
CYCLAFEM 7/7/7 ....................................... 49
CYCLESSA .......................................................... 49
cyclobenzaprine hcl ..................................... 126
CYCLOGYL .................................................... 129
CYCLOMYDRIL ..................................... 129
cyclopentolate hcl .......................................... 129
CYCLOSET .......................................................... 23
cyclosporine ............................................................ 44
cyclosporine modified .................................. 44
cylate ........................................................................... 129
CYMBALTA ...................................................... 20
CYOTIC ................................................................ 133
cyproheptadine hcl ........................................... 28
CYSTADANE ................................................... 77
CYSTAGON ....................................................... 82
CYSTARAN .................................................... 129
CYSTO-CONRAY II ............................... 69
CYSTOGRAFIN-DILUTE ............. 69
CYTOGAM ...................................................... 134
CYTOMEL ........................................................ 138
CYTOTEC .......................................................... 139
CYTOVENE ........................................................ 41
cytra k crystals .................................................... 82
cytra-2 ........................................................................... 82
CYTRA-3 ................................................................ 82
cytra-k ........................................................................... 82
D.H.E. 45 .............................................................. 115
DALIRESP ............................................................ 15
danazol ......................................................................... 12
DANTRIUM ................................................... 126
dantrolene sodium ......................................... 126
DARAPRIM ....................................................... 35
DASETTA 1/35 ................................................ 49
DASETTA 7/7/7 .............................................. 49
DAYPRO .................................................................... 5
DAYSEE .................................................................. 49
DAYTRANA ......................................................... 3
DDAVP ...................................................................... 77
DEBACTEROL ........................................... 118
DECON-A .............................................................. 54
DECON-G .............................................................. 54
deferoxamine mesylate ............................... 26
delta d3 ..................................................................... 143
Index
Index
CONTROLRX .............................................. 118
CONZIP ........................................................................ 8
COPAXONE .................................................... 136
COPEGUS .............................................................. 41
CORDARONE ................................................ 14
CORDRAN ................................................ 58, 59
COREG ...................................................................... 45
COREG CR .......................................................... 45
corenate-dha ....................................................... 120
CORGARD .......................................................... 45
CORIFACT .......................................................... 84
CORLANOR ...................................................... 48
CORMAX ............................................................... 59
CORMAX SCALP
APPLICATION ............................................... 59
CORNWALL METAL
PIPETTING ......................................................... 95
CORTALO ............................................................ 59
CORTANE-B ........................................ 59, 133
CORTEF .................................................................. 53
CORTENEMA ................................................. 12
CORTIC-ND ................................................... 133
CORTIFOAM ................................................... 12
CORTISPORIN ................................. 59, 133
CORTISPORIN-TC ............................... 133
CORVITA ........................................................... 120
CORVITA 150 ................................................... 85
CORZIDE ............................................................... 31
COSENTYX ........................................................ 59
COSENTYX SENSOREADY PEN
................................................................................................ 59
COSOPT ................................................................ 129
COSOPT PF ...................................................... 129
COUMADIN ...................................................... 17
COVARYX ........................................................... 79
COVARYX HS ................................................ 79
COZAAR ................................................................. 31
CPB WC .................................................................... 54
CREON ...................................................................... 75
CRESEMBA ........................................................ 27
CRESTOR .............................................................. 29
CRESYLATE ................................................. 133
CRINONE .......................................................... 142
CRIXIVAN ........................................................... 41
CRNATAL ......................................................... 120
cromolyn sodium ....................... 15, 81, 129
CRYSELLE-28 ................................................. 49
CUPRIMINE ..................................................... 44
CURITY ALCOHOL PREPS ....... 95
CURITY ALCOHOL SWABS ..... 95
CURITY STERILE SALINE ........ 82
CUROSURF .................................................... 137
CUTIVATE .......................................................... 59
CUVPOSA .......................................................... 139
CVS ADVANCED GLUCOSE
TEST .............................................................................. 69
cvs alcohol prep swabs ................................ 95
cvs alcohol swabs ............................................... 95
(Updated 07/01/15)
151
duane reade test .................................................. 69
duane reade unifine pentips ................... 96
DUAVEE ................................................................. 79
DUET DHA ..................................................... 120
DUET DHA 400 .......................................... 120
DUET DHA 400EC ................................ 120
DUET DHA 430 .......................................... 120
DUET DHA 430EC ................................ 120
DUET DHA BALANCED ............ 120
DUET DHA EC .......................................... 120
DUETACT ............................................................ 23
DUEXIS ....................................................................... 6
DULERA ................................................................ 15
duloxetine hcl ........................................................ 20
DUO-CARE CONTROL
SOLUTION .......................................................... 96
DUO-CARE TEST ...................................... 69
DUONEB ................................................................ 15
DUOPA ..................................................................... 38
DURAGESIC-100 ........................................... 9
DURAGESIC-12 ............................................... 9
DURAGESIC-25 ............................................... 9
DURAGESIC-50 ............................................... 9
DURAGESIC-75 ............................................... 9
DURAPREP ........................................................ 41
duraxin ............................................................................. 7
DUREZOL ......................................................... 129
DUTOPROL ....................................................... 32
D-VI-SOL ............................................................. 143
D-VITA ................................................................... 143
DYAZIDE .............................................................. 75
DYMISTA .......................................................... 127
DYRENIUM ...................................................... 75
DYSPORT .......................................................... 128
E.E.S. 400 ................................................................. 90
E.E.S. GRANULES ................................... 90
E.S.P. ............................................................................. 34
earloop mask .......................................................... 96
EASIVENT ............................................................ 96
EASIVENT MASK LARGE .......... 96
EASIVENT MASK MEDIUM ... 96
EASIVENT MASK SMALL .......... 96
easy comfort insulin syringe ................. 96
easy comfort lancets ...................................... 96
easy comfort pen needles .......................... 96
easy mini lancing device ............................ 96
easy plus blood glucose test ................... 69
easy plus control ................................................ 96
easy plus ii control ........................................... 96
easy plus ii glucose test ............................... 69
EASY STEP CONTROL ..................... 96
EASY STEP TEST ....................................... 69
easy talk blood glucose test ................... 69
easy talk control ................................................. 96
EASY TOUCH ALCOHOL PREP
MEDIUM ............................................................... 96
EASY TOUCH CONTROL HIGH
& LOW ........................................................................ 96
Index
DIOVAN .................................................................. 32
DIOVAN HCT ................................................. 32
DIPENTUM ........................................................ 81
diphenatol .................................................................. 26
diphenoxylate-atropine .............................. 26
DIPROLENE ..................................................... 59
DIPROLENE AF .......................................... 59
dipyridamole ........................................................... 84
discount drug mart test ............................... 69
disopyramide phosphate ............................ 14
disulfiram ............................................................... 136
DITROPAN XL .......................................... 142
DIURIL ..................................................................... 75
divalproex sodium ............................................ 18
divalproex sodium er ..................................... 18
DIVIGEL ................................................................. 79
DIVISTA .................................................................. 85
DOLOPHINE ........................................................ 8
donepezil hcl ........................................................ 136
DONNATAL .................................................. 139
DONNATAL EXTENTABS ...... 139
DORAL ..................................................................... 88
DORYX ................................................................. 138
dorzolamide hcl ................................................ 129
dorzolamide hcl-timolol mal ............. 129
DOVONEX ........................................................... 59
doxazosin mesylate ......................................... 32
doxepin hcl ............................................................... 20
doxycycline .............................................................. 59
doxycycline hyclate ..................................... 138
doxycycline monohydrate .................... 138
DOXYTEX ............................................................ 28
DRISDOL ........................................................... 143
DRITHO-CREME HP ........................... 59
dronabinol ................................................................. 27
DROPLET LANCETS ULTRA
THIN 30G ............................................................... 96
DROPLET LANCING DEVICE
................................................................................................ 96
drospirenone-ethinyl estradiol ............ 49
DROXIA .................................................................. 85
drug emporium test ......................................... 69
drug mart glucose ............................................. 23
drug mart lancets thin 26g ...................... 96
drug mart lancets ultra thin .................. 96
DRUG MART LANCING
DEVICE .................................................................... 96
DRUG MART ON-THE-GO
LANCET 30G .................................................... 96
drug mart unifine pentips ......................... 96
DRUG MART UNILET
LANCETS 28G ................................................ 96
DRUG MART UNILET
LANCETS 30G ................................................ 96
DUAC .......................................................................... 59
duane reade lancet altern site .............. 96
duane reade lancet super thin .............. 96
duane reade lancet ultra thin ............... 96
Index
Index
DEXPAK 13 DAY ....................................... 53
DEXPAK 6 DAY .......................................... 53
dextroamphetamine sulfate ...................... 4
dextroamphetamine sulfate er ............... 4
DIABETA ............................................................... 23
diabetic.com test ................................................ 69
DIALYVITE .................................................... 120
DIALYVITE 3000 ..................................... 120
DIALYVITE 5000 ..................................... 120
DIALYVITE SUPREME D ......... 120
DIALYVITE/ZINC ................................. 120
DIAMOX SEQUELS ............................... 75
DIASTAR EASY TEST II
LANCETS .............................................................. 96
DIASTAR EASY TEST
LANCETS .............................................................. 96
DIASTAT ACUDIAL ............................ 17
DIASTAT PEDIATRIC ....................... 17
DIASTIX .................................................................. 69
diatrue control level 1 .................................. 96
diatrue plus test ................................................... 69
diazepam ..................................................................... 14
DIAZEPAM INTENSOL ................... 14
DIBENZYLINE ............................................. 31
DICLEGIS ............................................................. 27
diclofenac potassium ........................................ 5
diclofenac sodium ......................... 5, 59, 129
diclofenac sodium er ......................................... 5
diclofenac-misoprostol ................................... 6
dicloxacillin sodium .................................... 135
dicyclomine hcl ................................................. 139
didanosine .................................................................. 41
DIFFERIN ............................................................ 59
DIFICID ................................................................... 89
DIFIL-G FORTE .......................................... 15
diflorasone diacetate ..................................... 59
DIFLUCAN ......................................................... 27
diflunisal ......................................................................... 7
DIGIBAR 190 .................................................... 69
DIGOX ....................................................................... 47
digoxin .......................................................................... 47
dihydroergotamine mesylate ............. 115
DILACOR XR .................................................. 46
DILANTIN ........................................................... 17
DILANTIN INFATABS ..................... 17
DILATRATE-SR .......................................... 13
DILAUDID ............................................................. 8
dilt-cd ............................................................................. 46
diltiazem hcl ............................................................ 46
diltiazem hcl cd .................................................... 46
diltiazem hcl er .................................................... 46
diltiazem hcl er beads ................................... 46
diltiazem hcl er coated beads ............... 46
dilt-xr ............................................................................. 46
diltzac ............................................................................ 47
DIMETANE DX ........................................... 54
(Updated 07/01/15)
152
EMBRACE EVO BLOOD
GLUCOSE TEST .......................................... 70
EMBRACE PRO GLUCOSE
TEST .............................................................................. 70
EMCYT ..................................................................... 36
EMEND .................................................................... 27
EMLA .......................................................................... 60
EMOQUETTE .................................................. 49
EMSAM .................................................................... 20
EMTRIVA ............................................................. 41
enalapril maleate ............................................... 32
enalapril-hydrochlorothiazide ............. 32
ENBREL ...................................................................... 6
ENCARE .............................................................. 142
ENDOCET ................................................................ 9
ENDODAN ............................................................. 9
ENDOMETRIN .......................................... 142
ENDUR-ACIN ............................................. 143
ENJUVIA ................................................................ 79
enoxaparin sodium .......................................... 17
ENPRESSE-28 .................................................. 49
ENSKYCE ............................................................. 49
entacapone ................................................................ 38
entecavir ...................................................................... 41
ENTERO VU ..................................................... 70
ENTOCORT EC ............................................ 53
enulose ........................................................................... 81
ENVISION AUTOCODE TEST
................................................................................................ 70
ENVISION CONTROL ........................ 98
EPANED .................................................................. 32
EPIDRIN .............................................................. 115
EPIDUO .................................................................... 60
EPIFLUR ............................................................. 116
EPIFOAM .............................................................. 60
EPIKLOR ............................................................ 116
epinastine hcl ...................................................... 129
epinephrine hcl ..................................................... 15
EPIPEN 2-PAK ............................................ 143
EPIPEN JR ........................................................ 143
EPIPEN JR 2-PAK .................................. 143
EPITOL ...................................................................... 18
EPIVIR ....................................................................... 41
EPIVIR HBV ....................................................... 41
eplerenone ................................................................. 32
epoprostenol sodium ...................................... 48
eprosartan mesylate ....................................... 32
EPZICOM ............................................................... 41
eql color lancets 21g ...................................... 98
eql color lancets micro 33g .................... 98
eql niacin ................................................................. 143
eql short pen needle ........................................ 98
eql super thin lancets 30g ......................... 98
eql thin lancets 26g ......................................... 98
EQL TRUETEST TEST ....................... 70
EQL TRUETRACK TEST ............... 70
eql ultra short pen needle ......................... 98
EQUAGESIC ......................................................... 7
Index
ECLIPSE CONTROL ............................. 97
ECLIPSE TEST ............................................... 70
EC-NAPROSYN ............................................... 6
econazole nitrate ................................................ 59
ECOZA ....................................................................... 59
ed baclofen ............................................................ 126
ED CHLORPED ............................................ 28
ED CYTE F .......................................................... 85
EDARBI ................................................................... 32
EDARBYCLOR ............................................. 32
ED-CHLOR-TAN ........................................ 28
EDECRIN .............................................................. 75
EDEX ........................................................................... 48
ED-FLEX ................................................................... 7
EDLUAR ................................................................ 88
ed-spaz ....................................................................... 139
EDURANT ........................................................... 41
EEMT ........................................................................... 79
EEMT HS ................................................................ 79
EFFER-K ............................................................. 116
effervescent pot chloride ........................ 116
EFFEXOR XR ................................................. 20
EFFIENT ................................................................ 84
EFLOW SCF AEROSOL HEAD
................................................................................................ 97
EFUDEX ................................................................. 59
ELAPRASE .......................................................... 77
ELDEPRYL ......................................................... 38
ELELYSO ............................................................... 85
element compact control 2 ...................... 97
element compact control 3 ...................... 97
element compact test ..................................... 70
ELEMENT CONTROL ....................... 97
ELEMENT PLUS CONTROL .... 98
ELEMENT PLUS TEST ...................... 70
ELEMENT TEST ......................................... 70
ELESTAT ............................................................ 129
ELESTRIN ............................................................ 79
ELIDEL ..................................................................... 59
ELIGARD .............................................................. 36
ELIMITE ................................................................. 60
ELINEST ................................................................. 49
ELIPHOS ................................................................. 81
ELIQUIS .................................................................. 17
ELITE DC AUTO ADAPTER .... 98
ELITE-OB ........................................................... 120
ELITE-OB 400 ............................................... 120
elite-thin insulin syringe ............................ 98
ELIXOPHYLLIN ......................................... 15
ELLA ............................................................................ 49
ELMIRON ............................................................. 82
ELOCON ................................................................. 60
EMADINE ......................................................... 129
EMBEDA ................................................................... 9
EMBRACE BLOOD GLUCOSE
TEST .............................................................................. 70
EMBRACE CONTROL ....................... 98
Index
Index
EASY TOUCH HEALTHPRO
TEST .............................................................................. 70
EASY TOUCH INSULIN
SAFETY SYR ......................................... 96, 97
EASY TOUCH INSULIN
SYRINGE ............................................................... 97
................................................................................................ 97
................................................................................................ 97
................................................................................................ 97
................................................................................................ 97
EASY TOUCH LANCETS
28G/TWIST ........................................................... 97
................................................................................................ 97
EASY TOUCH LANCETS
30G/TWIST ........................................................... 97
................................................................................................ 97
EASY TOUCH LANCETS
32G/TWIST ........................................................... 97
EASY TOUCH LANCETS
33G/TWIST ........................................................... 97
EASY TOUCH LANCING
DEVICE .................................................................... 97
EASY TOUCH PEN NEEDLES
................................................................................................ 97
EASY TOUCH SAFETY
LANCETS 21G ................................................ 97
EASY TOUCH SAFETY
LANCETS 23G ................................................ 97
EASY TOUCH SAFETY
LANCETS 26G ................................................ 97
EASY TOUCH SAFETY
LANCETS 28G ................................................ 97
EASY TOUCH TEST .............................. 70
easy trak blood glucose test .................. 70
easy trak control ................................................ 97
EASY TWIST & CAP LANCETS
................................................................................................ 97
EASYGLUCO ................................................... 70
EASYGLUCO CONTROL .............. 97
EASYMAX 15 LEVEL 1
CONTROL ............................................................ 97
EASYMAX 15 LEVEL 2
CONTROL ............................................................ 97
EASYMAX 15 TEST ................................ 70
EASYMAX CONTROL ...................... 97
EASYMAX TEST ........................................ 70
easyplus blood glucose test ..................... 70
EASYPRO BLOOD GLUCOSE
TEST .............................................................................. 70
EASYPRO PLUS .......................................... 70
EASYTEST II LANCETS .................. 97
EASYTEST LANCETS ......................... 97
(Updated 07/01/15)
153
famotidine ................................................ 139, 140
FAMVIR .................................................................. 42
FANAPT .................................................................. 39
FANAPT TITRATION PACK ... 39
FARESTON ......................................................... 36
FARXIGA .............................................................. 23
FARYDAK ........................................................... 36
FASLODEX ......................................................... 36
FASTTAKE TEST ...................................... 70
fa-vitamin b-6-vitamin b-12 .................. 85
FAZACLO ............................................................. 39
FC FEMALE CONDOM ................... 98
FC2 FEMALE CONDOM ................ 98
fe 90 plus ..................................................................... 85
FEIBA NF .............................................................. 84
FEIBA VH IMMUNO ............................ 84
felbamate ................................................................... 18
FELBATOL .......................................................... 18
FELDENE ................................................................. 6
felodipine er ............................................................. 47
FEM PH ................................................................. 142
FEMARA ................................................................ 36
FEMCAP ................................................................. 98
FEMCON FE ..................................................... 50
FEMHRT 1/5 ...................................................... 79
FEMHRT LOW DOSE ......................... 79
FEMRING ......................................................... 142
fenofibrate ................................................................ 29
fenofibrate micronized ................................ 29
fenofibric acid ....................................................... 29
FENOGLIDE ..................................................... 29
fenoprofen calcium ............................................. 6
fentanyl ............................................................................ 9
fentanyl citrate ........................................................ 9
FENTORA ................................................................ 9
FER-IN-SOL ....................................................... 85
fer-iron .......................................................................... 85
FERIVA .................................................................... 85
FERIVAFA .......................................................... 85
ferocon .......................................................................... 85
ferotrinsic .................................................................. 85
FERRALET 90 ................................................ 85
ferraplus 90 .............................................................. 86
ferrex 150 forte ................................................... 86
FERREX 150 FORTE PLUS ......... 86
FERREX 28 ......................................................... 86
FERRIPROX ..................................................... 27
FERRLECIT ....................................................... 86
FERROCITE PLUS .................................. 86
FERROGELS FORTE .......................... 86
FERRO-PLEX HEMATINIC ...... 86
FERROTRIN ..................................................... 86
ferrous sulfate ....................................................... 86
FETZIMA ............................................................... 20
FETZIMA TITRATION ..................... 20
FEXMID ............................................................... 127
fexofenadine hcl ................................................. 28
fexofenadine-pseudoephed er ............... 55
Index
EVOCLIN ............................................................... 60
EVOLUTION AUTOCODE .......... 70
EVOLUTION CONTROL ................ 98
EVOTAZ .................................................................. 42
EVOXAC .............................................................. 118
EVZIO ......................................................................... 26
EXACTECH R-S-G TEST ................ 70
EXACTECH TEST ..................................... 70
EXACTUSS .......................................................... 54
EXALGO .................................................................... 9
EXELDERM ...................................................... 60
EXELON .............................................................. 136
exemestane ............................................................... 36
EXFORGE ............................................................ 32
EXFORGE HCT ............................................ 32
EXJADE ................................................................... 27
EXODERM .......................................................... 60
exotic-hc .................................................................. 133
express med test strip pack .................... 70
EXTAVIA ............................................................ 136
EXTINA ................................................................... 60
extra-virt plus dha ........................................ 120
EYLEA .................................................................... 129
E-Z JECT LANCET
MICRO-THIN 33G .................................... 98
E-Z JECT LANCET SUPER
THIN 30G ............................................................... 98
E-Z JECT LANCETS ............................... 98
E-Z JECT LANCETS 21G ................. 98
E-Z JECT LANCETS THIN 26G
................................................................................................ 98
EZ SMART BLOOD GLUCOSE
LANCETS .............................................................. 98
EZ SMART BLOOD GLUCOSE
TEST .............................................................................. 70
EZ SMART PLUS GLUCOSE
TEST .............................................................................. 70
E-Z SPACER ...................................................... 98
E-Z SPACER THE BODY
GUARDS PK ..................................................... 98
E-Z-CAT DRY ................................................. 70
E-Z-DISK ................................................................ 70
E-Z-DOSE ............................................................... 70
E-Z-HD ...................................................................... 70
EZ-LETS LANCETS 21G .................. 98
EZ-LETS LANCETS 23G .................. 98
EZ-LETS LANCETS 26G .................. 98
EZ-LETS LANCETS 28G .................. 98
EZ-LETS LANCETS 30G .................. 98
E-Z-PAQUE ......................................................... 70
E-Z-PASTE ........................................................... 70
fabb ................................................................................... 85
FABIOR .................................................................... 60
FABRAZYME ................................................. 77
FACTIVE ................................................................ 80
fa-cyanocobalamin-pyridoxine .......... 85
FALMINA ............................................................. 49
famciclovir ................................................................ 42
Index
Index
EQUETRO ............................................................ 39
ergocalciferol ..................................................... 143
ERGOMAR ...................................................... 115
ERIVEDGE .......................................................... 36
ERRIN ........................................................................ 49
ERTACZO ............................................................. 60
ery ...................................................................................... 60
ERYGEL .................................................................. 60
ERYPED 200 ...................................................... 90
ERYPED 400 ...................................................... 90
ERY-TAB ................................................................ 90
ERYTHROCIN STEARATE ....... 90
erythromycin ............................................ 60, 129
erythromycin base ............................................ 90
erythromycin-sulfisoxazole ................... 34
ESBRIET .............................................................. 137
ESCAVITE ......................................................... 120
escitalopram oxalate ..................................... 20
ESGIC ............................................................................. 7
esomeprazole magnesium ..................... 139
esomeprazole strontium ......................... 139
est estrogens-methyltest ............................ 79
est estrogens-methyltest ds .................... 79
est estrogens-methyltest hs .................... 79
ESTARYLLA .................................................... 49
estazolam ................................................................... 88
ESTRACE ................................................. 79, 142
ESTRADERM .................................................. 79
estradiol ....................................................................... 79
estradiol-norethindrone acet ................ 79
ESTRASORB ..................................................... 79
ESTRING ............................................................ 142
ESTROGEL ......................................................... 79
estropipate ................................................................ 79
ESTROSTEP FE ............................................ 49
eszopiclone ............................................................... 88
ethambutol hcl ...................................................... 35
ethosuximide .......................................................... 18
etidronate disodium ........................................ 77
etodolac ........................................................................... 6
etodolac er .................................................................... 6
EURAX ..................................................................... 60
EVAMIST ............................................................... 79
EVEKEO ..................................................................... 4
EVENCARE + BLOOD
GLUCOSE TEST .......................................... 70
EVENCARE BLOOD GLUCOSE
TEST .............................................................................. 70
EVENCARE CONTROL
LOW/HIGH ......................................................... 98
EVENCARE G2 LOW/HIGH
CONTROL ............................................................ 98
EVENCARE G2 TEST .......................... 70
EVENCARE G3 LOW/HIGH
CONTROL ............................................................ 98
EVENCARE G3 TEST .......................... 70
EVICEL ..................................................................... 88
EVISTA ...................................................................... 77
(Updated 07/01/15)
154
FORA D20 BLOOD GLUCOSE
TEST .............................................................................. 71
FORA G20 BLOOD GLUCOSE
TEST .............................................................................. 71
FORA G30A BLOOD GLUCOSE
TEST .............................................................................. 71
FORA G71A BLOOD GLUCOSE
TEST .............................................................................. 71
FORA G90 BLOOD GLUCOSE
TEST .............................................................................. 71
FORA GD20 TEST .................................... 71
FORA LANCETS ........................................ 99
FORA LANCING DEVICE ........... 99
FORA V10 BLOOD GLUCOSE
TEST .............................................................................. 71
TEST .............................................................................. 71
TEST .............................................................................. 71
TEST .............................................................................. 71
FORA V30A BLOOD GLUCOSE
TEST .............................................................................. 71
FORACARE GD40 TEST ................. 71
FORACARE GDH CONTROL
................................................................................................ 99
FORACARE PREMIUM V10
TEST .............................................................................. 71
FORACARE TEST N GO TEST
................................................................................................ 71
FORADIL AEROLIZER ................... 16
FORANE ................................................................. 82
FORFIVO XL .................................................... 21
FORMADON .................................................... 41
formaldehyde ......................................................... 41
FORMA-RAY .................................................. 41
FORTEO .................................................................. 77
FORTESTA .......................................................... 12
FOSAMAX ........................................................... 77
FOSAMAX PLUS D ................................ 77
FOSCAVIR ........................................................... 42
fosinopril sodium ............................................... 32
fosinopril sodium-hctz ................................. 32
FOSRENOL ......................................................... 81
FRAGMIN ............................................................ 17
freds pharmacy autolet lancing ......... 99
freds pharmacy unifine pentip+ ........ 99
freds pharmacy unifine pentips .......... 99
freds pharmacy unilet lanc 28g ......... 99
freds pharmacy unilet lanc 30g ......... 99
FREESTYLE CONTROL
SOLUTION .......................................................... 99
FREESTYLE INSULINX TEST
................................................................................................ 71
FREESTYLE LANCETS ................... 99
FREESTYLE LITE TEST ................. 71
FREESTYLE PRECISION INS
SYR ................................................................................. 99
Index
fluorescein-benoxinate ............................. 129
FLUORIDEX DAILY DEFENSE
............................................................................................. 118
FLUORIDEX ENHANCED
WHITENING ................................................ 118
FLUORIDEX SENSITIVITY
RELIEF .................................................................. 118
FLUOR-I-STRIPS A.T. ..................... 129
fluoritab ................................................................... 117
fluorometholone .............................................. 129
FLUOROPLEX ............................................... 60
fluorouracil .............................................................. 60
fluoxetine hcl ......................................................... 20
fluoxetine hcl (pmdd) .............................. 136
fluphenazine hcl .................................................. 39
FLURA-DROPS ......................................... 117
FLURA-SAFE .............................................. 129
flurazepam hcl ...................................................... 88
flurbiprofen ................................................................. 6
flurbiprofen sodium ..................................... 129
FLUROX ............................................................. 129
flutamide ..................................................................... 36
fluticasone propionate .................... 60, 127
fluvastatin sodium ............................................ 29
fluvoxamine maleate ..................................... 21
fluvoxamine maleate er .............................. 20
FML ............................................................................ 129
FML FORTE .................................................. 130
FML LIQUIFILM ................................... 130
focalgin-b ................................................................ 120
FOCALIN .................................................................. 4
FOCALIN XR ...................................................... 4
folbee .............................................................................. 86
folbee plus .............................................................. 120
FOLBEE PLUS CZ ................................. 120
folcal dha ................................................................ 120
FOLCAPS ............................................................... 86
FOLCAPS OMEGA 3 .......................... 120
FOLGARD OS ............................................. 120
folic acid ...................................................................... 86
FOLIVANE-EC CALCIUM DHA
NF .................................................................................. 120
FOLIVANE-F ................................................... 86
FOLIVANE-OB ........................................... 120
FOLIVANE-PLUS ...................................... 86
FOLIVANE-PRX DHA NF ........ 120
folplex 2.2 ................................................................. 86
foltrin .............................................................................. 86
fondaparinux sodium .................................... 17
FORA CONTROL ...................................... 99
FORA D10 BLOOD GLUCOSE
TEST .............................................................................. 71
FORA D15C BLOOD GLUCOSE
TEST .............................................................................. 71
FORA D15G BLOOD GLUCOSE
TEST .............................................................................. 71
FORA D15Z BLOOD GLUCOSE
TEST .............................................................................. 71
Index
Index
FIBRICOR ............................................................ 29
FIFTY50 ALCOHOL PREP ........... 98
FIFTY50 CONTROL 2.0 .................... 98
FIFTY50 GLUCOSE TEST 2.0
................................................................................................ 70
FIFTY50 LANCING DEVICE ... 98
FIFTY50 PEN NEEDLES ................ 98
FIFTY50 SAFETY SEAL
LANCETS .............................................................. 98
FIFTY50 SUPERIOR COMFORT
SYR ................................................................................. 98
filter air pp ............................................................... 98
FINACEA ............................................................... 60
finasteride .................................................................. 82
FINE 30 ..................................................................... 99
FINGERSTIX LANCETS ................ 99
FIORICET ................................................................ 8
FIORICET/CODEINE .............................. 9
FIORINAL ............................................................... 8
FIORINAL/CODEINE #3 ................... 9
FIRAZYR ............................................................... 84
FIRMAGON ...................................................... 36
FIRST-PROGESTERONE VGS
100 .................................................................................. 142
200 .................................................................................. 142
25 ..................................................................................... 142
400 .................................................................................. 142
50 ..................................................................................... 142
FIRST-VANCOMYCIN 25 ............. 34
FIRST-VANCOMYCIN 50 ............. 34
FLAGYL .................................................................. 34
FLAGYL ER ...................................................... 34
FLAREX ............................................................... 129
FLEBOGAMMA ....................................... 134
FLEBOGAMMA DIF ......................... 134
flecainide acetate .............................................. 14
FLECTOR .............................................................. 60
FLOMAX ................................................................ 82
FLO-PRED ........................................................... 53
FLOVENT DISKUS ................................. 16
FLOVENT HFA ............................................ 16
FLUCAINE ...................................................... 129
fluconazole ..................................................... 27, 28
flucytosine ................................................................. 28
fludrocortisone acetate ............................... 53
FLUMADINE .................................................. 42
flunisolide ............................................................... 127
fluocinolone acetonide ................... 60, 133
fluocinolone acetonide body .................. 60
fluocinolone acetonide scalp ................. 60
fluocinonide ............................................................. 60
fluocinonide-e ........................................................ 60
FLUORABON .............................................. 116
FLUOR-A-DAY ......................................... 116
(Updated 07/01/15)
155
GLUCOLAB CONTROL .................. 99
GLUCOLAB TEST .................................... 71
GLUCOLET 2 AUTOMATIC
LANCING ............................................................. 99
GLUCONAVII BLOOD
GLUCOSE TEST .......................................... 71
GLUCOPHAGE ............................................ 23
GLUCOPHAGE XR ................................ 23
GLUCOPRO INSULIN
SYRINGE ........................................................... 100
glucose ........................................................................... 23
glucose control .................................................. 100
GLUCOSOURCE LANCET
DEVICE ................................................................. 100
GLUCOSOURCE LANCETS
............................................................................................. 100
GLUCOSTIX ..................................................... 71
GLUCOTROL .................................................. 23
GLUCOTROL XL ...................................... 23
GLUCOVANCE ............................................ 23
GLUMETZA ...................................................... 23
GLUTOSE 15 ..................................................... 23
GLUTOSE 45 ..................................................... 23
glyburide ..................................................................... 24
glyburide micronized ..................................... 24
glyburide-metformin ...................................... 24
GLYCATE ......................................................... 140
glycine ........................................................................... 82
glycine urologic ................................................... 82
glycopyrrolate ................................................... 140
GLYNASE ............................................................. 24
GLYSET ................................................................... 24
GLYXAMBI ........................................................ 24
GMATE BLOOD GLUCOSE
TEST .............................................................................. 71
GMATE CONTROL LEVEL 2
............................................................................................. 100
gnp alcohol swabs .......................................... 100
gnp clickfine pen needles ....................... 100
gnp glucose ............................................................... 24
gnp lancets ............................................................ 100
gnp lancets 21g ................................................. 100
gnp lancets micro thin 33g .................. 100
gnp lancets super thin 30g ................... 100
gnp lancets thin ................................................ 100
gnp lancets thin 26g .................................... 100
gnp micro thin lancets 33g .................. 100
gnp niacin ............................................................... 143
gnp niacin tr ......................................................... 143
gnp quick dissolve glucose ....................... 24
gnp super thin lancets 30g ................... 100
GOLYTELY ........................................................ 89
GORDOFILM .................................................. 60
GORDONS UREA ..................................... 60
grafco silver nit applicator ..................... 60
GRALISE ............................................................ 136
GRALISE STARTER .......................... 136
granisetron hcl ..................................................... 27
Index
GENTLE-LET LANCETS ............... 99
GENTLE-LET PLATFORMS ..... 99
GEODON ............................................................... 39
GESTICARE DHA ................................. 120
ght test .......................................................................... 71
giant eagle pharm test ................................. 71
GIANVI ..................................................................... 50
GIAZO ........................................................................ 81
GILDAGIA .......................................................... 50
GILDESS 1.5/30 .............................................. 50
GILDESS 1/20 ................................................... 50
GILDESS 24 FE .............................................. 50
GILDESS FE 1.5/30 ................................... 50
GILDESS FE 1/20 ........................................ 50
GILENYA ........................................................... 136
GILOTRIF ............................................................ 36
GILPHEX TR .................................................... 55
GILTUSS ................................................................. 55
GILTUSS PED-C .......................................... 55
GILTUSS TR ..................................................... 55
GLASSIA ............................................................. 137
GLEEVEC .............................................................. 36
GLEOSTINE ...................................................... 36
glimepiride ................................................................ 23
glipizide ........................................................................ 23
glipizide er ................................................................ 23
GLIPIZIDE XL ............................................... 23
glipizide-metformin hcl .............................. 23
global alcohol prep ease ............................ 99
global ease inject pen needles .............. 99
global inject ease insulin syr ................. 99
global inject ease lancets 28g .............. 99
global inject ease lancets 30g .............. 99
global lancing device ..................................... 99
GLUCAGEN HYPOKIT ................... 23
GLUCAGON EMERGENCY ..... 23
GLUCO BURST ............................................ 23
GLUCO PERFECT 3 TEST ........... 71
GLUCOCARD 01 CONTROL ... 99
GLUCOCARD 01 SENSOR PLUS
................................................................................................ 71
GLUCOCARD EXPRESSION
CONTROL ............................................................ 99
GLUCOCARD EXPRESSION
TEST .............................................................................. 71
GLUCOCARD SHINE ......................... 99
GLUCOCARD SHINE
CONTROL ............................................................ 99
GLUCOCARD SHINE TEST ...... 71
GLUCOCARD VITAL TEST ...... 71
GLUCOCARD X-SENSOR ........... 71
GLUCOCARD X-SENSOR
CONTROL ............................................................ 99
GLUCOCOM CONTROL ................ 99
GLUCOCOM LANCETS 28G .... 99
GLUCOCOM TEST .................................. 71
Index
Index
FREESTYLE TEST ................................... 71
FREESTYLE UNISTICK II
LANCETS .............................................................. 99
FROVA ................................................................... 115
FUL-GLO ............................................................ 130
full kit nebulizer set ........................................ 99
FULYZAQ ............................................................ 26
FURADANTIN .......................................... 141
furosemide ................................................................ 75
FUSION PLUS ................................................ 86
FUZEON ................................................................. 42
FYCOMPA ........................................................... 18
gabapentin ................................................................ 18
GABITRIL ............................................................ 18
galantamine hydrobromide ................. 136
galantamine hydrobromide er ......... 136
GALZIN ................................................................ 117
GAMASTAN S/D ..................................... 134
GAMMAGARD ......................................... 134
GAMMAGARD S/D ............................ 134
GAMMAGARD S/D LESS IGA
............................................................................................. 134
GAMMAPLEX ............................................ 134
GAMUNEX ..................................................... 134
GAMUNEX-C .............................................. 134
ganciclovir sodium ........................................... 42
GANITE ................................................................... 77
gani-tuss nr .............................................................. 55
GARAMYCIN .............................................. 130
GASTRINEX NF ...................................... 140
GASTROCROM ............................................ 81
GASTROGRAFIN ..................................... 71
GASTROMARK ........................................... 71
gatifloxacin .......................................................... 130
GATTEX .................................................................. 81
gavilax ........................................................................... 89
GAVILYTE-C ................................................... 89
GAVILYTE-G .................................................. 89
GAVILYTE-H .................................................. 89
GAVILYTE-N WITH FLAVOR
PACK ........................................................................... 89
ge100 blood glucose test ............................ 71
ge100 control ......................................................... 99
GEBAUERS PAIN EASE ................. 60
GEBAUERS SPRAY AND
STRETCH .............................................................. 60
GELCLAIR ....................................................... 118
GELFILM ........................................................... 130
GELX ........................................................................ 118
gemfibrozil ............................................................... 29
GENERESS FE ............................................... 50
generlac ........................................................................ 81
GENGRAF ........................................................... 44
GENOTROPIN ............................................... 77
GENOTROPIN MINIQUICK .... 77
GENTAK ............................................................. 130
gentamicin sulfate .............................. 60, 130
GENTLE-LET GP LANCETS .... 99
(Updated 07/01/15)
156
HUMULIN N KWIKPEN ............... 24
HUMULIN N PEN .................................... 24
HUMULIN R U-500
(CONCENTRATED) .............................. 24
HYCAMTIN ....................................................... 36
HYCET .......................................................................... 9
hydralazine hcl ..................................................... 32
hydrochlorothiazide ............................. 75, 76
hydrocod polst-cpm polst er .................. 55
hydrocodone-acetaminophen ................... 9
hydrocodone-homatropine ...................... 55
hydrocodone-ibuprofen .................................. 9
hydrocortisone ................................. 12, 53, 61
hydrocortisone ace-pramoxine
...................................................................................... 12, 61
hydrocortisone acetate ................................ 12
hydrocortisone acetate-aloe .................. 61
hydrocortisone butyr lipo base ........... 61
hydrocortisone butyrate ............................ 61
hydrocortisone valerate .............................. 61
hydrocortisone-acetic acid .................. 133
hydrocortisone-iodoquinol ...................... 61
hydromet ..................................................................... 55
hydromorphone hcl ............................................. 9
hydroxychloroquine sulfate ................... 35
hydroxyurea ........................................................... 36
hydroxyzine hcl ................................................... 14
hydroxyzine pamoate ................................... 14
hygel ................................................................................ 61
HYLIRA ................................................................... 61
HYOMAX-SL ................................................ 140
HYOPHEN ........................................................ 141
hyoscyamine sulfate ................................... 140
hyoscyamine sulfate er ............................ 140
hyosyne ..................................................................... 140
HYPERCARE ................................................... 61
HYPERHEP B S/D .................................. 134
HYPERSAL ......................................................... 55
HYPERTET S/D ......................................... 134
HYPOLANCE AST LANCING
............................................................................................. 101
HYQVIA ............................................................... 134
HYSINGLA ER ................................................. 9
HYSKON ................................................................ 72
hy-vee glucose ....................................................... 24
HY-VEE LANCETS .............................. 101
hy-vee thin lancets ........................................ 101
HYZAAR ................................................................ 32
ibandronate sodium ........................................ 77
IBRANCE ............................................................... 36
IBUDONE ................................................................. 9
ibuprofen ........................................................................ 6
ICLUSIG .................................................................. 36
IFEREX 150 FORTE ............................... 86
ILARIS ........................................................................... 6
ILEVRO ................................................................. 130
ILOTYCIN ......................................................... 130
IMBRUVICA ..................................................... 36
Index
HEATHER ............................................................ 50
h-e-b incontrol adv lancing ................. 101
h-e-b incontrol lancets 28g .................. 101
h-e-b incontrol lancets 30g .................. 101
h-e-b incontrol pen needles .................. 101
HECORIA .............................................................. 44
HELIXATE FS ................................................ 84
HEMA-COMBISTIX ............................... 72
hematinic plus complex .............................. 86
hematinic plus vit/minerals ..................... 86
hematinic/folic acid ........................................ 86
HEMATOGEN FA .................................... 86
HEMATOGEN FORTE ...................... 86
hemenatal ob ...................................................... 120
hemenatal ob + dha .................................... 120
hemetab ........................................................................ 86
HEMOCYTE PLUS .................................. 86
HEMOCYTE-F ............................................... 86
hemocyte-plus ....................................................... 86
HEMOFIL M ..................................................... 84
hemorrhoidal-hc ................................................. 12
HEMRIL-30 ......................................................... 12
HEPAGAM B ................................................. 134
HEPSERA .............................................................. 42
HETLIOZ ................................................................ 88
HEXALEN ............................................................ 36
HIPREX ................................................................ 141
HIZENTRA ...................................................... 134
hm glucose ................................................................ 24
hm lancets micro thin 33g .................... 101
hm lancets ultra thin 30g ...................... 101
hm niacin ................................................................. 143
HOMATROPAIRE ................................ 130
homatropine hbr ............................................. 130
HUMALOG KWIKPEN .................... 24
HUMALOG MIX 50/50 ....................... 24
HUMALOG MIX 50/50
KWIKPEN ............................................................ 24
HUMALOG MIX 75/25 ....................... 24
HUMALOG MIX 75/25
KWIKPEN ............................................................ 24
HUMATE-P ......................................................... 84
HUMATROPE ................................................ 77
HUMATROPEN FOR 12MG
............................................................................................. 101
HUMATROPEN FOR 24MG
............................................................................................. 101
HUMATROPEN FOR 6MG ...... 101
HUMIRA .................................................................... 6
HUMIRA PEDIATRIC CROHNS
START ........................................................................... 6
HUMIRA PEN .................................................... 6
HUMIRA PEN-CROHNS
STARTER .................................................................. 6
HUMIRA PEN-PSORIASIS
STARTER .................................................................. 6
HUMULIN 70/30 KWIKPEN ...... 24
HUMULIN 70/30 PEN .......................... 24
Index
Index
GRANISOL ......................................................... 27
GRANIX .................................................................. 86
GRIFULVIN V ................................................ 28
griseofulvin microsize ................................... 28
griseofulvin ultramicrosize ..................... 28
GRIS-PEG .............................................................. 28
grx hicort 25 ........................................................... 12
guaiatussin ac ........................................................ 55
guaifenesin ac ........................................................ 55
guaifenesin dac .................................................... 55
guaifenesin-codeine ......................................... 55
guanfacine hcl ....................................................... 32
guanfacine hcl er ................................................... 4
GYNAZOLE-1 .............................................. 142
GYNOL II ........................................................... 142
GYNOL II EXTRA STRENGTH
............................................................................................. 142
............................................................................................. 100
............................................................................................. 100
HAEMOLANCE ........................................ 100
HAEMOLANCE LOW FLOW
LANCETS ........................................................... 100
HAEMOLANCE PLUS .................... 100
HAEMOLANCE PLUS HIGH
FLOW ....................................................................... 100
HAEMOLANCE PLUS LOW
FLOW ....................................................................... 100
HAEMOLANCE PLUS MAX
FLOW ....................................................................... 100
HAEMOLANCE PLUS
PEDIATRIC FLOW .............................. 100
HALCION .............................................................. 88
halobetasol propionate ................................ 60
HALOG ..................................................................... 60
haloperidol ................................................................ 39
haloperidol lactate ........................................... 39
HALOTIN .............................................................. 60
HARVONI ............................................................. 42
HEALTH ALLIANCE .......................... 71
HEALTH CARE LANCING
DEVICE ................................................................. 100
healthwise alcohol prep ........................... 100
healthwise lancets 30g .............................. 100
healthwise lancing pen ............................. 100
healthwise mini pen needles ............... 100
healthwise pen needles ............................. 100
healthwise short pen needles ............. 100
healthwise unifine pentips .................... 100
healthy accents lancing device ........ 100
healthy accents unifine pentip ......... 100
healthy accents unilet lancets ........... 101
HEALTHY LIVING FILTERS
............................................................................................. 101
HEALTHY LIVING MASKS ... 101
HEALTHY LIVING
REPLACEMENT KIT ....................... 101
(Updated 07/01/15)
157
KAZANO ................................................................ 24
KCENTRA ............................................................ 84
k-effervescent ..................................................... 117
KEFLEX .................................................................. 48
KELNOR 1/35 ................................................... 50
KENALOG ........................................................... 61
KEPPRA .................................................................. 18
KEPPRA XR ...................................................... 18
KERAFOAM ..................................................... 61
KERAFOAM 42 ............................................ 61
KERALAC ............................................................ 61
KERLONE ............................................................ 45
kerr drug test strip pack ............................ 72
KERR TRIPLE DYE SWABS ..... 41
KERYDIN ............................................................. 61
KETEK ...................................................................... 34
KETOCARE ....................................................... 72
ketoconazole ................................................ 28, 61
KETODAN ........................................................... 61
KETO-DIASTIX ............................................ 72
ketoprofen .................................................................... 6
ketoprofen er ............................................................. 6
ketorolac tromethamine .................. 6, 130
KETOSTIX ........................................................... 72
KHEDEZLA ....................................................... 21
kinney lancets .................................................... 101
kinney thin lancets ........................................ 101
kinray test ................................................................. 72
KIONEX .................................................................. 44
KLARON ................................................................ 61
KLONOPIN ......................................................... 18
KLOR-CON ..................................................... 117
KLOR-CON 10 ............................................. 117
KLOR-CON M10 ...................................... 117
KLOR-CON M15 ...................................... 117
KLOR-CON M20 ...................................... 117
KLOR-CON/EF .......................................... 117
kmart valu insulin syringe 29g ........ 101
kmart valu insulin syringe 30g ........ 101
KOATE-DVI ....................................................... 84
KOGENATE FS ............................................ 84
KOGENATE FS BIO-SET ............... 84
KOKO PEAK PRO
MOUTHPIECE ............................................ 101
KOMBIGLYZE XR .................................. 24
KORLYM ............................................................... 24
kp cetirizine hcl ................................................... 28
kp miconazole nitrate ................................... 61
kp omeprazole magnesium .................. 140
K-PHOS ................................................................. 117
K-PHOS NO 2 ................................................... 82
K-PRIME ............................................................. 117
KRISTALOSE .................................................. 89
kroger blood glucose test .......................... 72
kroger glucose ...................................................... 24
kroger lancets .................................................... 101
kroger lancets 21g ........................................ 101
kroger lancets micro thin 33g .......... 101
Index
ipratropium bromide ........................ 16, 127
ipratropium-albuterol ................................... 16
IPRIVASK ............................................................. 17
irbesartan ................................................................... 32
irbesartan-hydrochlorothiazide ......... 32
IROSPAN 24/6 .................................................. 86
ISENTRESS ......................................................... 42
ISOCHRON ......................................................... 13
isoditrate er ............................................................. 13
isoflurane ................................................................... 82
isometheptene-apap-dichloral .......... 115
isoniazid ...................................................................... 35
ISOPTIN SR ........................................................ 47
ISOPTO CARBACHOL ................... 130
ISOPTO HOMATROPINE .......... 130
ISOPTO HYOSCINE ........................... 130
ISORDIL TITRADOSE ....................... 13
isosorbide dinitrate .......................................... 13
isosorbide dinitrate er .................................. 13
isosorbide mononitrate ............................... 13
isosorbide mononitrate er ........................ 13
ISTALOL ............................................................. 130
itraconazole ............................................................. 28
ivermectin .................................................................. 13
JADENU .................................................................. 27
JAKAFI ..................................................................... 37
JALYN ........................................................................ 82
JANTOVEN ......................................................... 17
JANUMET ............................................................ 24
JANUMET XR ................................................ 24
JANUVIA ............................................................... 24
JARDIANCE ..................................................... 24
JENCYCLA ......................................................... 50
JENTADUETO ............................................... 24
JETREA ................................................................. 130
JEVANTIQUE .................................................. 79
JOLESSA ................................................................. 50
JOLIVETTE ......................................................... 50
J-TIP KIT W/VIAL ADAPTERS
............................................................................................. 101
JUBLIA ...................................................................... 61
JUNEL 1.5/30 ..................................................... 50
JUNEL 1/20 .......................................................... 50
JUNEL FE 1.5/30 .......................................... 50
JUNEL FE 1/20 ................................................ 50
JUXTAPID ........................................................... 29
KADIAN ..................................................................... 9
KALBITOR .......................................................... 84
KALETRA ............................................................ 42
kalexate ....................................................................... 44
KALYDECO ................................................... 137
KAPVAY .................................................................... 4
KARBINAL ER ............................................. 28
KARIDIUM ..................................................... 117
KARIGEL ........................................................... 118
KARIGEL-N ................................................... 118
KARIVA .................................................................. 50
KAYEXALATE ............................................. 44
Index
Index
IMDUR ..................................................................... 13
imipramine hcl ...................................................... 21
imipramine pamoate ...................................... 21
imiquimod .................................................................. 61
IMITREX ............................................................ 115
IMITREX STATDOSE SYSTEM
............................................................................................. 115
IMPLANON ........................................................ 50
IMURAN ................................................................ 44
INATAL ADVANCE ........................... 120
INATAL GT .................................................... 120
INATAL ULTRA ..................................... 120
INCIVEK ................................................................ 42
INCRELEX .......................................................... 77
INCRUSE ELLIPTA ............................... 16
indapamide ............................................................... 76
INDERAL LA .................................................. 45
INDERAL XL .................................................. 45
INDOCIN .................................................................. 6
indomethacin ............................................................. 6
indomethacin er ...................................................... 6
infanate balance .............................................. 120
INFASURF ....................................................... 137
INFINITY BLOOD GLUCOSE
TEST .............................................................................. 72
INFINITY CONTROL ...................... 101
inhaler companions ...................................... 101
inject-ease .............................................................. 101
INJECT-EASE AUTOMATIC
INJECTOR ........................................................ 101
INLYTA ................................................................... 36
INNOSPIRE REPLACEMENT
FILTER .................................................................. 101
INSPIREASE .................................................. 101
INSPIREASE BAGS ............................. 101
INSPIREASE MOUTHPIECE
............................................................................................. 101
INSPIREASE RESERVOIR
BAGS ......................................................................... 101
INSPRA ..................................................................... 32
INSTA-GLUCOSE ..................................... 24
insupen pen needles ...................................... 101
INSUPEN SENSITIVE ...................... 101
INSUPEN ULTRAFIN ..................... 101
INTEGRA F ........................................................ 86
INTEGRA PLUS .......................................... 86
INTELENCE ...................................................... 42
INTERMEZZO ............................................... 88
INTROL ................................................................... 76
INTRON-A ........................................................... 37
INTROVALE ..................................................... 50
INTUNIV ................................................................... 4
INVEGA ................................................................... 40
INVIRASE ............................................................. 42
INVOKAMET .................................................. 24
INVOKANA ....................................................... 24
iophen c-nr ................................................................ 55
IOPIDINE ........................................................... 130
(Updated 07/01/15)
158
LIDAZONE HC ............................................. 12
lidocaine ...................................................................... 61
lidocaine hcl ............................................... 61, 118
lidocaine viscous ............................................. 118
lidocaine-hydrocortisone ace ............... 12
lidocaine-prilocaine ........................................ 61
LIDODERM ....................................................... 61
lidopin ............................................................................ 61
lidorx .............................................................................. 61
life medical test ................................................... 72
LIFESCAN UNISTIK 2 ................... 102
LIFESCAN UNISTIK II
LANCETS ........................................................... 102
LILETTA ................................................................. 50
lindane ........................................................................... 61
LINZESS .................................................................. 81
liothyronine sodium ..................................... 138
LIPITOR .................................................................. 29
LIPOFEN ................................................................ 30
LIPTRUZET ....................................................... 30
LIQUID E-Z-PAQUE ............................. 72
LIQUID POLIBAR .................................... 72
LIQUID POLIBAR PLUS ................ 72
lisinopril ....................................................................... 32
lisinopril-hydrochlorothiazide ............. 32
lite touch lancets ............................................. 102
LITE TOUCH LANCING
DEVICE ................................................................. 102
LITE TOUCH LANCING PEN
............................................................................................. 102
LITE TOUCH PEN NEEDLES
............................................................................................. 102
LITEAIRE .......................................................... 102
LITETOUCH INSULIN
SYRINGE ........................................................... 102
LITETOUCH LANCETS ............... 102
LITETOUCH MASK LARGE
............................................................................................. 102
LITETOUCH MASK MEDIUM
............................................................................................. 102
LITETOUCH MASK SMALL
............................................................................................. 102
LITETOUCH PEN NEEDLES
............................................................................................. 102
lithium carbonate .............................................. 40
lithium carbonate er ....................................... 40
LITHOBID ............................................................ 40
LITHOSTAT ....................................................... 83
LIVALO .................................................................... 30
live better adv lancing device ............ 102
live better lancet super thin ................ 102
live better lancet ultra thin .................. 103
live better pen needles ............................... 103
l-methylfolate pnv dha ............................. 121
LO LOESTRIN FE ..................................... 50
LOCOID ................................................................... 61
LOCOID LIPOCREAM ...................... 62
LOESTRIN 1.5/30 (21) ........................... 50
Index
leader quick dissolve glucose ................ 25
............................................................................................. 102
PLUS .......................................................................... 102
LEENA ....................................................................... 50
leflunomide .................................................................. 6
LEMTRADA .................................................. 136
................................................................................................ 37
................................................................................................ 37
................................................................................................ 37
................................................................................................ 37
LESCOL .................................................................... 29
LESCOL XL ........................................................ 29
LESSINA ................................................................. 50
LETAIRIS .............................................................. 48
letrozole ....................................................................... 37
leucovorin calcium ........................................... 37
LEUKERAN ...................................................... 37
LEUKINE .............................................................. 86
leuprolide acetate .............................................. 37
levalbuterol hcl .................................................... 16
LEVAQUIN ......................................................... 80
LEVATOL .............................................................. 45
LEVEMIR .............................................................. 25
LEVEMIR FLEXPEN ............................ 25
levetiracetam .......................................................... 18
levetiracetam er .................................................. 18
levobunolol hcl .................................................. 130
levocarnitine ........................................................... 77
levocetirizine dihydrochloride ............. 28
levofloxacin ................................................ 80, 130
levomefolate dha ............................................ 121
LEVONEST .......................................................... 50
levonorgest-eth estrad 91-day ............. 50
levonorgestrel ........................................................ 50
levonorgestrel-ethinyl estrad ................ 50
LEVORA 0.15/30 (28) .............................. 50
LEVOTHROID ............................................ 138
levothyroxine sodium ................................ 138
LEVOXYL .......................................................... 138
LEVULAN KERASTICK ................. 61
LEXAPRO ............................................................. 21
LEXIVA .................................................................... 42
LIALDA ................................................................... 81
............................................................................................. 102
MID ............................................................................. 102
LIBERTY MINI LANCING
DEVICE ................................................................. 102
LIBERTY NEXT GENERATION
TEST .............................................................................. 72
liberty test ................................................................. 72
Index
Index
kroger lancets super thin ....................... 101
kroger lancets thin ........................................ 102
kroger lancets thin 26g ............................ 102
kroger lancets ultrathin 30g .............. 102
kroger lancing device ................................. 102
kroger pen needles ........................................ 102
kroger premium glucose test ................ 72
kroger test ................................................................. 72
KRYSTEXXA ................................................... 83
KURVELO ............................................................ 50
KUVAN .................................................................... 77
k-vescent .................................................................. 117
labetalol hcl ............................................................. 45
LABSTIX ................................................................. 72
LACRISERT ................................................... 130
lactated ringers .................................................... 44
lactic acid ................................................................... 61
LACTOCAL-F .............................................. 121
lactulose ...................................................................... 89
lactulose encephalopathy ......................... 81
lady lite lancets ................................................ 102
LAMICTAL ......................................................... 18
LAMICTAL ODT ........................................ 18
LAMICTAL STARTER ...................... 18
LAMICTAL XR ............................................. 18
LAMISIL ................................................................. 28
lamivudine ................................................................. 42
lamivudine-zidovudine ................................. 42
lamotrigine ............................................................... 18
lamotrigine er ........................................................ 18
lancet device ........................................................ 102
lancets ........................................................................ 102
lancets 28g ............................................................ 102
lancets 30g ............................................................ 102
lancets micro thin 33g .............................. 102
lancets super thin 28g ............................... 102
lancets thin ............................................................ 102
LANCETS ULTRA FINE ............. 102
LANCETS ULTRA THIN ............ 102
lancets ultra thin 30g ................................. 102
lancing device ..................................................... 102
LANOXIN ............................................................. 47
lansoprazole ......................................................... 140
LANTUS .................................................................. 24
LANTUS SOLOSTAR ........................... 25
LARIN 1/20 .......................................................... 50
LARIN FE 1.5/30 .......................................... 50
LARIN FE 1/20 ................................................ 50
LASIX .......................................................................... 76
LASTACAFT ................................................. 130
latanoprost ............................................................ 130
LATRIX .................................................................... 61
LATUDA ................................................................ 40
lavare wound wash ........................................... 61
LAZANDA ............................................................... 9
LAZERFORMALYDE ........................ 41
leader advanced lancing device ...... 102
leader glucose ........................................................ 25
(Updated 07/01/15)
159
MEDLANCE PLUS EXTRA 21G
............................................................................................. 103
MEDLANCE PLUS LANCETS
............................................................................................. 103
MEDLANCE PLUS LITE 25G
............................................................................................. 103
MEDLANCE PLUS SPECIAL
0.8MM ...................................................................... 103
MEDLANCE PLUS SUPERLITE
30G ............................................................................... 103
MEDLANCE PLUS UNIVERSAL
21G ............................................................................... 103
MEDLANCE UNIVERSAL 21G
............................................................................................. 103
MEDROL ............................................................... 54
MEDROL (PAK) .......................................... 53
medroxyprogesterone acetate
.................................................................................. 51, 135
mefenamic acid ....................................................... 6
mefloquine hcl ....................................................... 35
MEGACE ES .................................................. 135
MEGACE ORAL .......................................... 37
megestrol acetate .............................................. 37
meijer alcohol swabs .................................. 103
meijer blood glucose test ........................... 72
meijer glucose ....................................................... 25
MEIJER LANCETS ............................... 103
MEIJER LANCETS THIN ........... 103
MEIJER LANCETS UNIVERSAL
21G ............................................................................... 103
30G ............................................................................... 103
33G ............................................................................... 103
meijer pen needles ......................................... 103
meijer premium glucose test ................. 72
MEIJER SUPER THIN
LANCETS ........................................................... 104
meijer test .................................................................. 72
MEIJER TRUETEST TEST ........... 72
MEIJER TRUETRACK TEST ... 72
MEKINIST ........................................................... 37
meloxicam .................................................................... 6
MELOXICAM COMFORT PAC
................................................................................................... 6
MENEST .................................................................. 79
MENOSTAR ...................................................... 80
meperidine hcl .......................................................... 9
meperitab ...................................................................... 9
MEPHYTON .................................................. 143
meprobamate ......................................................... 14
mercaptopurine ................................................... 37
mesalamine .............................................................. 81
MESNEX ................................................................. 37
MESTINON ......................................................... 35
METADATE CD .............................................. 4
METADATE ER .............................................. 4
metaproterenol sulfate ................................ 16
Index
LYZA ............................................................................ 51
MACNATAL CN DHA .................... 121
MACROBID .................................................... 141
MACRODANTIN ................................... 141
MACUGEN ...................................................... 130
mafenide acetate ................................................ 62
MAGELLAN INSULIN SAFETY
SYR .............................................................................. 103
major comfort lancets .............................. 103
MAKENA ........................................................... 135
MALARONE ..................................................... 35
malathion ................................................................... 62
margesic .......................................................................... 8
MARINOL ............................................................ 27
marlissa ........................................................................ 51
MARNATAL-F ........................................... 121
MARPLAN ........................................................... 21
marten-tab ................................................................... 8
martinic ........................................................................ 86
MASK VORTEX ....................................... 103
MATULANE ..................................................... 37
MATZIM LA ..................................................... 47
MAVIK ...................................................................... 33
MAXALT ............................................................ 116
MAXALT-MLT .......................................... 116
MAXARON FORTE ............................... 86
MAXIBAR ............................................................ 72
MAXI-COMFORT INSULIN
SYRINGE ........................................................... 103
MAXIDEX ......................................................... 130
MAXIMA BLOOD GLUCOSE
TEST .............................................................................. 72
MAXIMA CONTROL ....................... 103
MAXITROL ..................................................... 130
MAXZIDE ............................................................. 76
MAXZIDE-25 .................................................... 76
m-clear wc ................................................................. 55
MD-GASTROVIEW ................................ 72
medichoice safety lancet ........................ 103
medichoice safety lancet extra ....... 103
medichoice safety lancet norm ........ 103
medicine shoppe lancets ......................... 103
medicine shoppe lancets thin ............. 103
medicine shoppe pen needles ............. 103
medi-lance lancets ........................................ 103
MEDISENSE GLUCOSE
KETONE CONTR ................................... 103
MEDISENSE HI/MID/LOW
CONTROL ......................................................... 103
MEDISENSE HIGH/LOW
CONTROL ......................................................... 103
MEDISENSE MID CONTROL
............................................................................................. 103
MEDISENSE THIN LANCETS
............................................................................................. 103
MEDLANCE EXTRA 21G .......... 103
MEDLANCE LITE 25G .................. 103
Index
Index
LOESTRIN 1/20 (21) ................................. 51
LOESTRIN FE 1.5/30 .............................. 51
LOESTRIN FE 1/20 ................................... 51
lofene .............................................................................. 26
LOFIBRA ............................................................... 30
LOKARA ................................................................ 62
LOMOTIL .............................................................. 26
long test ....................................................................... 72
longs glucose .......................................................... 25
longs lancets standard .............................. 103
longs lancets thin ........................................... 103
longs lancets ultra thin ............................ 103
LONOX ..................................................................... 26
LOPID ......................................................................... 30
LOPRESSOR ...................................................... 45
LOPRESSOR HCT ..................................... 32
LOPROX .................................................................. 62
loratadine ................................................................... 29
lorazepam .................................................................. 14
LORAZEPAM INTENSOL ............ 14
LORCET ...................................................................... 9
LORCET HD ......................................................... 9
LORTAB ..................................................................... 9
LORYNA ................................................................ 51
LORZONE ......................................................... 127
losartan potassium ........................................... 32
losartan potassium-hctz ............................. 33
LOSEASONIQUE ....................................... 51
LOTEMAX ........................................................ 130
LOTENSIN ........................................................... 33
LOTENSIN HCT .......................................... 33
LOTREL ................................................................... 33
LOTRISONE ...................................................... 62
LOTRONEX ....................................................... 81
lovastatin .................................................................... 30
LOVAZA .................................................................. 30
LOVENOX ............................................................ 17
LOW-OGESTREL ....................................... 51
loxapine succinate ............................................ 40
LOXITANE .......................................................... 40
LOZI-FLUR ..................................................... 117
LTA 360 KIT ................................................... 118
LUCENTIS ........................................................ 130
LUDENT ............................................................. 117
LUFYLLIN .......................................................... 16
LUMIGAN ........................................................ 130
LUNESTA ............................................................. 88
LUPANETA PACK .................................. 77
LUPRON DEPOT ....................................... 37
LUPRON DEPOT-PED ....................... 77
LUTERA .................................................................. 51
LUVOX CR .......................................................... 21
LUXIQ ........................................................................ 62
LUZU ........................................................................... 62
LYNPARZA ........................................................ 37
LYRICA ................................................................... 18
LYSODREN ........................................................ 37
LYSTEDA .............................................................. 88
(Updated 07/01/15)
160
Index
MICRODOT TEST .................................... 72
MICROELITE BATTERY ........... 104
MICROELITE FILTER
REPLACEMENTS .................................. 104
MICROGESTIN 1.5/30 ......................... 51
MICROGESTIN 1/20 .............................. 51
MICROGESTIN FE 1.5/30 .............. 51
MICROGESTIN FE 1/20 .................... 51
MICRO-K ........................................................... 117
MICROLET LANCETS ................... 104
MICROLIFE DIGITAL PEAK
FLOW ....................................................................... 104
micronized colestipol hcl ........................... 30
MICROSPACER ....................................... 104
MICROTAINER SAFETY FLOW
LANCET ............................................................... 104
MICROZIDE ..................................................... 76
midazolam hcl ....................................................... 88
midodrine hcl ...................................................... 143
MIGERGOT .................................................... 116
migragesic ida ................................................... 116
MIGRAL .............................................................. 116
MIGRALAM .................................................. 116
MIGRANAL ................................................... 116
MILLIPRED ....................................................... 54
MILLIPRED DP ........................................... 54
MILLIPRED DP 12-DAY ................. 54
MIMVEY ................................................................ 80
MINASTRIN 24 FE .................................. 51
mini lancing device ....................................... 104
MINI WRIGHT PEAK FLOW
METER .................................................................. 104
MINIELITE FILTER
REPLACEMENTS .................................. 104
MINIELITE RECHARGEABLE
BATTERY .......................................................... 104
MINIPRESS ........................................................ 33
MINIPRIN LOW DOSE ......................... 8
MINIRIN ................................................................ 77
MINITRAN ......................................................... 13
MINIVELLE ....................................................... 80
MINOCIN ........................................................... 138
minocycline hcl ................................................. 138
minocycline hcl er ......................................... 138
minoxidil ..................................................................... 33
MIRAPEX .............................................................. 38
MIRAPEX ER .................................................. 38
MIRCERA ............................................................. 86
MIRCETTE .......................................................... 51
MIRENA ................................................................. 51
mirtazapine .............................................................. 21
MIRVASO .............................................................. 62
misoprostol ........................................................... 140
MITIGARE .......................................................... 83
MITOSOL ........................................................... 130
MOBIC ........................................................................... 6
modafinil ........................................................................ 4
MODERIBA ........................................................ 42
Index
Index
metaxalone ........................................................... 127
metformin hcl ........................................................ 25
metformin hcl er ................................................. 25
metformin hcl er (osm) ............................. 25
methadone hcl ................................................ 9, 10
METHADONE HCL INTENSOL
................................................................................................... 9
METHADOSE .................................................. 10
METHADOSE SUGAR-FREE
................................................................................................ 10
methamphetamine hcl ..................................... 4
methazolamide ..................................................... 76
methenamine hippurate ........................... 141
methenamine mandelate ........................ 141
methimazole ........................................................ 138
methitest ..................................................................... 12
methocarbamol ................................................ 127
methotrexate .......................................................... 37
methscopolamine bromide ................... 140
methyldopa ............................................................... 33
methylergonovine maleate ................... 134
METHYLIN ........................................................... 4
METHYLIN ER ................................................ 4
methylphenidate hcl ........................................... 4
methylphenidate hcl er ................................... 4
methylphenidate hcl er (cd) ..................... 4
methylphenidate hcl er (la) ...................... 4
methylprednisolone ......................................... 54
methylprednisolone (pak) ...................... 54
methyltest-est estrogens ............................ 80
methyltest-est estrogens hs .................... 80
metipranolol ........................................................ 130
metoclopramide hcl ........................................ 81
metolazone ............................................................... 76
METOPIRONE ............................................... 72
metoprolol succinate er .............................. 45
metoprolol tartrate ......................................... 45
metoprolol-hydrochlorothiazide ....... 33
METOZOLV ODT ...................................... 81
METROCREAM .......................................... 62
METROGEL ...................................................... 62
METROGEL-VAGINAL ............... 142
METROLOTION ......................................... 62
metronidazole ................................ 34, 62, 142
METVIXIA ........................................................... 62
MEVACOR .......................................................... 30
MEXAR WASH ............................................. 62
mexiletine hcl ........................................................ 14
MIACALCIN ..................................................... 77
micaderm .................................................................... 62
MICATIN ............................................................... 62
miconazole nitrate ........................................... 62
MICRO GUARD .......................................... 62
MICRO-BUMINTEST .......................... 72
MICROCHAMBER ............................... 104
MICRODOT CONTROL ............... 104
MICRODOT CONTROL
HIGH/LOW ...................................................... 104
................................................................................................
42
42
MODICON (28) .............................................. 51
moexipril hcl .......................................................... 33
moexipril-hydrochlorothiazide .......... 33
mometasone furoate ...................................... 62
MONOCLATE-P .......................................... 84
MONODOX ..................................................... 138
MONOJECT INSULIN
SYRINGE ........................................................... 104
MONOJECT ULTRA COMFORT
SYRINGE ........................................................... 104
MONOJECTOR END CAPS ..... 104
MONOJECTOR OPD END CAPS
............................................................................................. 104
MONOLET LANCETS ..................... 104
MONOLET OPD LANCETS .... 104
MONOLETTOR SAFETY
LANCETS ........................................................... 104
MONO-LINYAH ......................................... 51
MONONESSA .................................................. 51
MONONINE ...................................................... 84
monsels ferric subsulfate .......................... 88
montelukast sodium ....................................... 16
MONUROL ...................................................... 141
MOORE MONO INSULIN
SYRINGE ........................................................... 104
MORGIDOX .................................................. 138
morphine sulfate ................................................. 10
morphine sulfate (concentrate) ........ 10
morphine sulfate (pf) .................................. 10
morphine sulfate er ......................................... 10
MOTOFEN ........................................................... 26
MOVANTIK ....................................................... 81
MOVIPREP .......................................................... 89
MOXATAG ...................................................... 135
MOXEZA ............................................................ 131
MS CONTIN ....................................................... 10
ms quick dissolve glucose ......................... 25
MST 600 ........................................................................ 8
MUCOTROL .................................................. 118
MULTAQ ............................................................... 14
multi vit/fl .............................................................. 121
multi vita-bets/fluoride ............................ 121
multi vitamin/fluoride ............................... 121
MULTIGEN ........................................................ 86
MULTIGEN FOLIC ................................ 87
MULTIGEN PLUS .................................... 87
multi-lancet device ....................................... 104
multiple vitamins/fluoride .................... 121
MULTISTIX ....................................................... 72
MULTISTIX 10 SG .................................... 72
MULTISTIX 5 .................................................. 72
MULTISTIX 7 .................................................. 72
MULTISTIX 8 .................................................. 72
MULTISTIX 9 .................................................. 72
................................................................................................
(Updated 07/01/15)
161
NEOTUSS-D ...................................................... 55
NEPHPLEX RX .......................................... 121
NEPHROCAPS ............................................ 121
NEPHROCAPS QT ................................ 121
NEPHRON FA ................................................ 87
NEPHRONEX .............................................. 121
NEPTAZANE ................................................... 76
NESINA .................................................................... 25
NESSI SPACER WITH MASK
LARGE ................................................................... 104
NESSI SPACER WITH MASK
SM/MED ............................................................... 104
NESSI SPACER WITH
MOUTHPIECE ............................................ 104
NESTABS ............................................................ 121
NESTABS ABC ............................................ 121
NESTABS DHA .......................................... 121
NETGROUP LANCETS ................. 104
NEULASTA ........................................................ 87
NEUMEGA ......................................................... 87
NEUPOGEN ...................................................... 87
NEUPRO ................................................................. 38
neurin-sl ....................................................................... 87
NEURONTIN ........................................ 18, 19
NEUTEK 2TEK CONTROL ..... 104
NEUTEK 2TEK TEST .......................... 73
NEUTRAGARD ADVANCED
............................................................................................. 119
NEUTRASAL ................................................ 119
NEVANAC ........................................................ 131
nevirapine .................................................................. 42
nevirapine er ........................................................... 42
NEXA PLUS .................................................... 121
NEXA SELECT ........................................... 122
NEXAVAR ........................................................... 37
NEXGEN CONTROL ........................ 104
NEXGEN TEST ............................................. 73
NEXIUM .............................................................. 140
NEXPLANON .................................................. 51
NEXT CHOICE .............................................. 51
NEXT CHOICE ONE DOSE ........ 51
niacin ........................................................................... 144
niacin er ...................................................... 143, 144
niacin er (antihyperlipidemic) ........... 30
niacin-50 .................................................................. 144
NIACOR .................................................................. 30
NIASPAN ............................................................... 30
nicardipine hcl ...................................................... 47
NICAZELDOXY 30 .............................. 138
NICAZELDOXY 60 .............................. 138
NICODERM CQ ........................................ 136
NICOMIDE ...................................................... 122
nicotine ...................................................................... 136
nicotine polacrilex ........................................ 136
NICOTROL ...................................................... 136
NICOTROL NS ........................................... 136
NIFEDIAC CC ................................................ 47
NIFEDICAL XL ............................................ 47
Index
NAMENDA XR TITRATION
PACK ........................................................................ 136
NAMZARIC .................................................... 136
NAPRELAN ........................................................... 6
NAPROSYN ........................................................... 6
naproxen ........................................................................ 6
naproxen dr ................................................................. 6
naproxen sodium ................................................... 6
naproxen sodium er ........................................... 6
naratriptan hcl .................................................. 116
NARDIL .................................................................. 21
NASCOBAL ........................................................ 87
NASONEX ......................................................... 127
NATACHEW .................................................. 121
NATACYN ........................................................ 131
natal-v rx ................................................................ 121
NATALVIRT 90 DHA ....................... 121
NATALVIRT CA ...................................... 121
NATALVIRT FLT ...................................... 87
NATALVIT ....................................................... 121
NATAZIA .............................................................. 51
nateglinide ................................................................ 25
NATELLE ONE ......................................... 121
NATESTO .............................................................. 12
NATPARA ............................................................ 77
NATROBA ............................................................ 62
NATURE-THROID .............................. 138
NAVARRO BLOOD GLUCOSE
TEST .............................................................................. 73
nebulizer air tube/plugs ........................... 104
nebulizer mask pediatric ........................ 104
NEBUPENT ........................................................ 34
NEBUSAL ............................................................. 55
NECON 0.5/35 (28) ..................................... 51
NECON 1/35 (28) ........................................... 51
NECON 1/50 (28) ........................................... 51
NECON 10/11 (28) ....................................... 51
NECON 7/7/7 ...................................................... 51
NEEVO DHA ................................................. 121
nefazodone hcl ...................................................... 21
neo-fradin ...................................................................... 5
NEOFRIN ........................................................... 131
neomycin sulfate .................................................... 5
neomycin-bacitracin zn-polymyx
............................................................................................. 131
neomycin-polymyxin b gu ....................... 83
neomycin-polymyxin-dexameth .... 131
neomycin-polymyxin-gramicidin
............................................................................................. 131
neomycin-polymyxin-hc ......................... 133
NEO-POLYCIN .......................................... 131
NEO-POLYCIN HC .............................. 131
NEORAL ................................................................. 44
NEOSPORIN .................................................. 131
NEOSPORIN AF .......................................... 62
NEOSPORIN GU IRRIGANT
................................................................................................ 83
NEOTUSS PLUS ........................................... 55
Index
Index
MULTISTIX 9 SG ....................................... 72
multi-vit/fluoride ............................................ 121
multi-vit/fluoride/iron ............................... 121
multivitamin/fluoride ................................. 121
multi-vitamin/fluoride ............................... 121
multi-vitamin/fluoride/iron ................. 121
multivitamins/fluoride .............................. 121
multi-vitamins/fluoride ............................ 121
multi-vits/fluoride .......................................... 121
mult-vitamin/fluoride ................................ 121
mupirocin ................................................................... 62
mupirocin calcium ............................................ 62
MUSE ........................................................................... 48
MVC-FLUORIDE ................................... 121
MYAMBUTOL ............................................... 35
myci-gc ......................................................................... 55
mycophenolate mofetil ................................ 44
mycophenolic acid ............................................ 44
mydral ........................................................................ 131
MYDRIACYL ............................................... 131
myferon 150 forte ............................................. 87
MYGLUCOHEALTH CONTROL
............................................................................................. 104
MYGLUCOHEALTH LANCETS
30G ............................................................................... 104
MYGLUCOHEALTH TEST ......... 72
MYKIDZ IRON FL ............................... 121
MYLERAN .......................................................... 37
MYNATAL ....................................................... 121
MYNATAL ADVANCE ................. 121
mynephrocaps .................................................... 121
MYORISAN ........................................................ 62
MYOXIN ............................................................. 133
MYRBETRIQ ................................................ 142
MYSOLINE ......................................................... 18
mytussin ac .............................................................. 55
mytussin dac ........................................................... 55
MYZILRA ............................................................. 51
na ferric gluc cplx in sucrose ............... 87
NABI-HB ............................................................. 134
nabumetone ................................................................. 6
nadolol ........................................................................... 46
nadolol-bendroflumethiazide ................ 33
NAFRINSE ....................................................... 117
NAFRINSE DAILY
ACIDULATED ............................................ 118
NAFRINSE DAILY/NEUTRAL
............................................................................................. 118
NAFRINSE DROPS ............................. 117
NAFRINSE WEEKLY ...................... 118
NAFTIN ................................................................... 62
NAGLAZYME ................................................ 77
NALFON .................................................................... 6
naltrexone hcl ....................................................... 27
NAMENDA ..................................................... 136
NAMENDA TITRATION PAK
............................................................................................. 136
NAMENDA XR ......................................... 136
(Updated 07/01/15)
162
OB COMPLETE ......................................... 122
OB COMPLETE 400 .............................. 122
OB COMPLETE ONE ........................ 122
OB COMPLETE PETITE ............... 122
OB COMPLETE PREMIER ....... 122
OB COMPLETE/DHA ....................... 122
OB-NATAL ONE ...................................... 122
OBREDON ........................................................... 55
O-CAL PRENATAL ............................. 122
OCELLA .................................................................. 52
OCTAGAM ...................................................... 134
octreotide acetate ............................................. 78
OCUFEN ............................................................. 131
OCUFLOX ......................................................... 131
OCUVEL .............................................................. 122
OFEV ......................................................................... 137
ofloxacin .......................................... 80, 131, 133
olanzapine ................................................................. 40
olanzapine-fluoxetine hcl ...................... 136
olopatadine hcl ................................................. 127
OLUX ........................................................................... 63
OLUX-E .................................................................... 63
OLYSIO ..................................................................... 42
OMECLAMOX-PAK .......................... 140
omega-3-acid ethyl esters ........................ 30
omeprazole ............................................................ 140
omeprazole-sodium bicarbonate ... 140
OMNARIS ......................................................... 127
OMNIFLEX DIAPHRAGM ..... 105
OMNIPRED .................................................... 131
OMNITROPE ................................................... 78
OMNITROPE PEN 10 INJ
DEVICE ................................................................. 105
OMNITROPE PEN 5 INJ
DEVICE ................................................................. 105
OMONTYS ........................................................... 87
ON CALL EXPRESS BLOOD
GLUCOSE ............................................................. 73
ON CALL EXPRESS GLUCOSE
CONTR .................................................................. 105
ON CALL LANCETS .......................... 105
ON CALL LANCING DEVICE
............................................................................................. 105
ON CALL PLUS BLOOD
GLUCOSE ............................................................. 73
ON CALL PLUS GLUCOSE
CONTROL ......................................................... 105
ON CALL PLUS LANCETS ...... 105
ON CALL PLUS LANCING
DEVICE ................................................................. 105
ON CALL VIVID BLOOD
GLUCOSE ............................................................. 73
ON CALL VIVID GLUCOSE
CONTROL ......................................................... 105
ondansetron ............................................................. 27
ondansetron hcl ................................................... 27
ONE FLOW TESTER ......................... 105
Index
NOVA MAX PLUS GLU/KET
CONTROL ......................................................... 105
............................................................................................. 105
............................................................................................. 105
NOVA SUREFLEX LANCETS
............................................................................................. 105
NOVA SUREFLEX LANCING
DEVICE ................................................................. 105
NOVACORT ...................................................... 62
NOVAFERRUM .......................................... 87
NOVOEIGHT ................................................... 84
NOVOFINE ...................................................... 105
NOVOFINE AUTOCOVER ....... 105
NOVOLIN 70/30 ............................................ 25
NOVOLIN 70/30 RELION ............... 25
NOVOLIN N ...................................................... 25
NOVOLIN N RELION ......................... 25
NOVOLIN R ....................................................... 25
NOVOLIN R RELION ......................... 25
NOVOLOG ........................................................... 25
NOVOLOG FLEXPEN ........................ 25
NOVOLOG MIX 70/30 .......................... 25
NOVOLOG MIX 70/30 FLEXPEN
................................................................................................ 25
NOVOSEVEN RT ........................................ 84
NOVOTWIST ................................................. 105
NOXAFIL .............................................................. 28
np thyroid ............................................................... 138
NPLATE ................................................................... 87
NUCORT ................................................................ 62
NUCYNTA ........................................................... 10
NUCYNTA ER ............................................... 10
NUEDEXTA ................................................... 136
NUFOL ...................................................................... 87
NULECIT ............................................................... 87
NULEV ................................................................... 140
NULOJIX ............................................................... 44
NULYTELY WITH FLAVOR
PACKS ........................................................................ 89
NUOX .......................................................................... 62
nutri-tab ob + dha ........................................ 122
NUTRIVIT ........................................................ 122
NUTROPIN AQ ............................................. 77
NUTROPIN AQ NUSPIN 10 ....... 77
NUTROPIN AQ NUSPIN 20 ....... 77
NUTROPIN AQ NUSPIN 5 ........... 77
NUTROPIN AQ PEN ............................. 77
NUVARING ....................................................... 52
NUVESSA ........................................................... 142
NUVIGIL ................................................................... 4
NUZOLE ................................................................. 62
NYAMYC .............................................................. 62
NYMALIZE ........................................................ 47
nystatin ................................................. 28, 62, 119
nystatin-triamcinolone ................................ 62
NYSTOP ................................................................... 62
Index
Index
nifedipine .................................................................... 47
nifedipine er ............................................................. 47
nifedipine er osmotic ..................................... 47
NILANDRON .................................................. 37
nimodipine ................................................................ 47
NIRAVAM ............................................................ 14
nisoldipine er .......................................................... 47
NITRO-BID ......................................................... 13
NITRO-DUR ..................................................... 13
nitrofurantoin .................................................... 141
nitrofurantoin macrocrystal .............. 141
nitrofurantoin monohyd macro ...... 141
nitroglycerin ........................................................... 13
nitroglycerin er .................................................... 13
NITROLINGUAL ...................................... 13
NITROMIST ...................................................... 13
NITROSTAT ...................................................... 13
NITRO-TIME ................................................... 13
nizatidine ................................................................ 140
NIZORAL .............................................................. 62
NODOLOR ....................................................... 116
NORA-BE ............................................................... 51
NORCO ..................................................................... 10
NORDIPEN 5 INJECTION
DEVICE ................................................................. 104
NORDIPEN DELIVERY
SYSTEM ............................................................... 105
NORDITROPIN FLEXPRO ......... 77
NORDITROPIN NORDIFLEX
PEN ................................................................................. 77
norethin ace-eth estrad-fe ........................ 51
norethindrone ........................................................ 51
norethindrone acetate ............................... 135
norethindrone-eth estradiol ................... 80
norethin-eth estradiol-fe ............................ 51
norgestimate-eth estradiol ...................... 51
norgestim-eth estrad triphasic ............ 51
norgestrel-ethinyl estradiol .................... 51
NORINYL 1+35 (28) ................................ 51
NORINYL 1+50 (28) ................................ 52
NORITATE .......................................................... 62
NOROXIN ............................................................ 80
NORPACE ............................................................ 14
NORPACE CR ................................................. 14
NORPRAMIN .................................................. 21
NOR-QD .................................................................. 52
NORTHERA ................................................... 143
NORTREL 0.5/35 (28) ............................ 52
NORTREL 1/35 (21) .................................. 52
NORTREL 1/35 (28) .................................. 52
NORTREL 7/7/7 ............................................. 52
nortriptyline hcl .................................................. 21
nortuss-ex .................................................................. 55
NORVASC ............................................................ 47
NORVIR .................................................................. 42
nose clip .................................................................... 105
NOVA MAX GLUCOSE TEST
................................................................................................ 73
(Updated 07/01/15)
163
oxazepam ................................................................... 14
oxcarbazepine ....................................................... 19
OXECTA .................................................................. 10
OXISTAT ................................................................ 63
OXSORALEN ULTRA ........................ 63
OXTELLAR XR ............................................ 19
oxybutynin chloride .................................... 142
oxybutynin chloride er ............................. 142
oxycodone hcl ....................................................... 10
oxycodone hcl er ................................................ 10
oxycodone-acetaminophen ..................... 10
oxycodone-aspirin ............................................ 10
oxycodone-ibuprofen .................................... 10
OXYCONTIN ................................................... 10
oxymorphone hcl ............................................... 10
oxymorphone hcl er ........................................ 10
OXYTROL ......................................................... 142
OZURDEX ........................................................ 131
PACERONE ........................................................ 14
PAIRE OB ........................................................... 122
PALGIC .................................................................... 29
PAMELOR ............................................................ 21
pamidronate disodium ................................. 78
PAMINE ............................................................... 140
PAMINE FORTE ..................................... 140
PANCREAZE ................................................... 75
PANDA MASK LARGE ................ 106
PANDA MASK MEDIUM .......... 106
PANDA MASK SMALL ................. 106
PANDEL .................................................................. 63
PANRETIN .......................................................... 63
pantoprazole sodium .................................. 140
PARAFON FORTE DSC ............... 127
PARAGARD INTRAUTERINE
COPPER ................................................................... 52
parcaine .................................................................... 131
PAREMYD ....................................................... 131
PARI ALTERA NEBULIZER
HANDSET ......................................................... 106
PARI BABY CONVERSION KIT
............................................................................................. 106
PARI ERAPID NEBULIZER
HANDSET ......................................................... 106
PARI EXPIRATORY FILTER
SET ............................................................................... 106
PARI MASK SET ..................................... 106
PARI SOFT PLASTIC ADULT
MASK ...................................................................... 106
PARI SOFT PLASTIC PED
MASK ...................................................................... 106
paricalcitol ............................................................... 78
PARLODEL ........................................................ 38
PARNATE ............................................................. 21
paromomycin sulfate ........................................ 5
paroxetine hcl ....................................................... 21
paroxetine hcl er ................................................ 21
PASER ........................................................................ 35
PATADAY ......................................................... 131
Index
OPTIUM TEST ............................................... 73
OPTIUMEZ TEST ...................................... 73
OPTIVAR ............................................................ 131
OPTUMRX BLOOD GLUCOSE
TEST .............................................................................. 73
OPTUMRX GLUCOSE
CONTROL ......................................................... 106
ORACEA ................................................................. 63
ORACIT ................................................................... 83
ORAFATE ......................................................... 119
ORALONE ........................................................ 119
ORAMAGICRX ......................................... 119
ORAP ........................................................................ 137
ORAPRED ............................................................ 54
ORAPRED ODT ........................................... 54
ORAVIG ............................................................... 119
ORBIVAN CF ...................................................... 8
ORFADIN ............................................................. 78
orphenadrine citrate er ............................ 127
orphenadrine-aspirin-caffeine .......... 127
ORSINI INSULIN SYRINGE
............................................................................................. 106
ORSYTHIA .......................................................... 52
ORTHO DIAPHRAGM COIL
............................................................................................. 106
ORTHO DIAPHRAGM FLAT
............................................................................................. 106
ORTHO EVRA ................................................ 52
ORTHO MICRONOR ........................... 52
ORTHO TRI-CYCLEN (28) ........... 52
ORTHO TRI-CYCLEN LO ............ 52
ORTHO-CEPT (28) .................................... 52
ORTHO-CYCLEN (28) ......................... 52
ORTHO-EST 0.625 ..................................... 80
ORTHO-EST 1.25 ......................................... 80
ORTHO-NOVUM 1/35 (28) ............ 52
ORTHO-NOVUM 7/7/7 (28) ........... 52
oscimin ...................................................................... 140
oscimin sr ................................................................ 140
OSENI ......................................................................... 25
OSMOPREP ........................................................ 89
OTEZLA ...................................................................... 7
otic care .................................................................... 133
oticin ............................................................................ 133
OTICIN HC NR .......................................... 133
oto-end 10 .............................................................. 134
otomar ....................................................................... 134
otomax-hc .............................................................. 134
OTOZIN ................................................................ 134
OTREXUP ................................................................ 7
OVACE PLUS ................................................... 63
OVACE PLUS WASH ............................ 63
OVACE WASH ................................................ 63
OVCON-35 (28) ............................................... 52
OVIDE ........................................................................ 63
OXANDRIN ....................................................... 12
oxandrolone ............................................................ 12
oxaprozin ...................................................................... 7
Index
Index
ONETOUCH CLUB LANCETS
FINE PT ................................................................ 105
ONETOUCH COMBO PACK
............................................................................................. 105
ONETOUCH DELICA LANCETS
33G ............................................................................... 105
ONETOUCH DELICA LANCETS
FINE ........................................................................... 105
ONETOUCH DELICA
LANCING DEV ......................................... 105
ONETOUCH FINEPOINT
LANCETS ........................................................... 105
ONETOUCH LANCETS ................ 105
ONETOUCH SURESOFT
LANCING DEV ......................................... 105
ONETOUCH TEST ................................... 73
ONETOUCH ULTRA BLUE ....... 73
ONETOUCH ULTRA CONTROL
............................................................................................. 105
ONETOUCH ULTRASOFT
LANCETS ........................................................... 105
ONETOUCH VERIO ................ 73, 105
ONEXTON ........................................................... 63
ONFI ............................................................................. 19
ONGLYZA ........................................................... 25
ONMEL ..................................................................... 28
OPANA ...................................................................... 10
OPANA ER .......................................................... 10
opium .............................................................................. 26
OPSUMIT ............................................................... 48
OPTASE .................................................................... 63
OPTICHAMBER ADVANTAGE
............................................................................................. 105
OPTICHAMBER
ADVANTAGE-LG MASK .......... 105
OPTICHAMBER
ADVANTAGE-MED MASK .... 105
OPTICHAMBER
ADVANTAGE-SM MASK .......... 105
OPTICHAMBER DIAMOND
............................................................................................. 105
OPTICHAMBER DIAMOND-LG
MASK ...................................................................... 105
OPTICHAMBER
DIAMOND-MD MASK .................. 106
OPTICHAMBER DIAMOND-SM
MASK ...................................................................... 106
OPTICHAMBER FACE
MASK-LARGE ........................................... 106
OPTICHAMBER FACE
MASK-MEDIUM ..................................... 106
OPTICHAMBER FACE
MASK-SMALL ............................................ 106
OPTIHALER .................................................. 106
OPTIONS CONCEPTROL ........... 142
OPTIONS GYNOL II
CONTRACEPTIVE ............................... 143
OPTIPRANOLOL .................................... 131
(Updated 07/01/15)
164
PLEXION CLEANSING CLOTH
................................................................................................ 63
PLIAGLIS .............................................................. 63
pnv fe fum/docusate/folic acid ......... 122
pnv ob+dha ........................................................... 122
pnv-dha ...................................................................... 122
pnv-dha+docusate ......................................... 122
pnv-first .................................................................... 122
pnv-omega ............................................................. 122
pnv-select ................................................................ 122
pnv-total ................................................................... 122
POCKET CHAMBER ......................... 107
POCKET PEAK FLOW METER
............................................................................................. 107
POCKET SPACER .................................. 107
POCKETCHEM EZ CONTROL
............................................................................................. 107
POCKETCHEM EZ TEST ............... 73
POCKETPEAK PEAK FLOW
METER .................................................................. 107
podactin ....................................................................... 63
podocon ........................................................................ 63
podofilox ..................................................................... 63
POLIBAR ACB ............................................... 73
POLYCIN ............................................................ 131
polycin b .................................................................. 131
poly-dex ................................................................... 131
polyethylene glycol 3350 ....................... 135
poly-iron 150 forte ........................................... 87
polymyxin b-trimethoprim .................. 131
polysaccharide iron forte .......................... 87
POLYTRIM ...................................................... 131
POLY-VI-FLOR ......................................... 122
POLY-VI-FLOR/IRON ..................... 122
polyvitamin/fluoride ................................... 122
poly-vitamin/fluoride ................................. 122
POMALYST ........................................................ 37
PONSTEL .................................................................. 7
PORTIA-28 ........................................................... 52
pot bicarb-pot chloride ............................ 117
POTABA ............................................................... 144
potassium bicarbonate ............................. 117
potassium chloride ........................................ 118
potassium chloride crys er ................... 117
potassium chloride er ................................ 117
potassium citrate-citric acid ................. 83
POTIGA .................................................................... 19
PR NATAL 400 ............................................ 122
PRADAXA ........................................................... 17
pramcort ..................................................................... 13
pramipexole dihydrochloride ............... 38
pramipexole dihydrochloride er ........ 38
PRAMOSONE .................................................. 63
PRAMOSONE E ........................................... 63
pramoxine-hc-chloroxylenol aq .... 134
PRANDIMET ................................................... 25
PRANDIN ............................................................. 25
PRASCION ........................................................... 63
Index
PERSONAL BEST FULL
RANGE .................................................................. 106
PERSONAL BEST LOW RANGE
............................................................................................. 106
PERTZYE ............................................................... 75
PEXEVA ................................................................... 21
PFLEX ..................................................................... 106
pharmacist choice alcohol .................... 107
PHARMACIST CHOICE
AUTOCODE ...................................................... 73
pharmacist choice lancets .................... 107
PHARMACY COUNTER
LANCETS ........................................................... 107
PHENADOZ ....................................................... 29
PHENAZO ............................................................ 83
phenazopyridine hcl ........................................ 83
phenelzine sulfate .............................................. 21
phenobarbital ......................................................... 88
phenylephrine hcl ........................................... 131
phenylhistine dh .................................................. 55
PHENYTEK ........................................................ 19
phenytoin .................................................................... 19
PHENYTOIN INFATABS ............... 19
phenytoin sodium extended .................... 19
PHILITH .................................................................. 52
PHOS-FLUR ................................................... 119
PHOSLO ................................................................... 81
PHOSLYRA ........................................................ 81
PHOSPHA 250 NEUTRAL .......... 117
PHOSPHASAL ............................................. 141
PHOSPHOLINE IODIDE ............. 131
PHYSIOLYTE .................................................. 44
PHYSIOSOL IRRIGATION ......... 44
PICATO ..................................................................... 63
PIKO 1 ..................................................................... 107
pillow mask/adult .......................................... 107
pillow mask/child ........................................... 107
pillow mask/pediatric ................................ 107
pilocarpine hcl ..................................... 119, 131
PILOPINE HS ................................................ 131
PIMTREA .............................................................. 52
pinnacaine otic .................................................. 134
pioglitazone hcl ................................................... 25
pioglitazone hcl-glimepiride .................. 25
pioglitazone hcl-metformin hcl .......... 25
PIRMELLA 1/35 ............................................ 52
PIRMELLA 7/7/7 .......................................... 52
piroxicam ...................................................................... 7
PLAQUENIL ..................................................... 35
plastic adapter .................................................. 107
PLAVIX ..................................................................... 84
PLEGRIDY ...................................................... 137
PLEGRIDY STARTER PACK
............................................................................................. 137
PLETAL .................................................................... 84
PLEXION ............................................................... 63
PLEXION CLEANSER ........................ 63
Index
Index
PATANASE ...................................................... 127
PATANOL ......................................................... 131
PAXIL ......................................................................... 21
PAXIL CR .............................................................. 21
PAZEO .................................................................... 131
pc lancets super thin 30g ....................... 106
pc unifine pentips ........................................... 106
pca injector ........................................................... 106
PCCA ACACIA SYRUP BASE
............................................................................................. 135
PCE .................................................................................. 90
PEAK AIR PEAK FLOW METER
............................................................................................. 106
PEDIAPRED ...................................................... 54
PEDIATEX TDM ........................................ 55
pediatric aerosol mask ............................. 106
pediatric mouthpiece .................................. 106
PEDIATRIC PANDA MASK
............................................................................................. 106
pedi-dri ......................................................................... 63
peg 3350/electrolytes .................................... 89
peg 3350-kcl-na bicarb-nacl ................. 89
peg-3350/electrolytes .................................... 89
PEGANONE ....................................................... 19
PEGASYS ............................................................... 42
PEGASYS PROCLICK ........................ 42
PEG-INTRON .................................................. 42
PEG-INTRON REDIPEN ................ 42
PEG-INTRON REDIPEN PAK 4
................................................................................................ 42
PEG-PREP ............................................................. 89
pen needles ............................................................ 106
pen needles 1/2" ............................................... 106
pen needles 3/16" ............................................ 106
pen needles 5/16" ............................................ 106
penicillin v potassium ................................ 135
PENLAC .................................................................. 63
PENLET II BLOOD SAMPLER
............................................................................................. 106
PENLET II REPLACEMENT
CAP .............................................................................. 106
PENNSAID .......................................................... 63
PENTASA .............................................................. 81
pentoxifylline er ................................................. 84
PEPCID .................................................................. 140
PERCOCET ......................................................... 10
PERCODAN ....................................................... 10
PERFECT LANCETS 28G ........... 106
PERFECT LANCETS 30G ........... 106
PERFOROMIST ............................................ 16
PERIDEX ............................................................ 119
perindopril erbumine ..................................... 33
PERIOGARD ................................................ 119
PERIOMED ..................................................... 119
permethrin ................................................................ 63
perphenazine .......................................................... 40
PERSANTINE .................................................. 84
(Updated 07/01/15)
165
PRILOSEC OTC ......................................... 140
primidone ................................................................... 19
PRIMLEV ............................................................... 10
PRIMSOL ............................................................... 34
PRINIVIL ............................................................... 33
PRINZIDE ............................................................ 33
PRISTIQ ................................................................... 21
PRIVIGEN ......................................................... 135
PROAIR HFA ................................................... 16
PROAIR RESPICLICK ....................... 16
probenecid ................................................................. 83
PROCARDIA .................................................... 47
PROCARDIA XL ........................................ 47
PROCENTRA ...................................................... 4
prochlorperazine ................................................ 40
prochlorperazine maleate ........................ 40
PROCORT ............................................................. 13
PROCRIT ............................................................... 87
PROCTOCARE-HC ................................. 13
PROCTOCREAM HC ........................... 13
PROCTOFOAM HC ................................ 13
PROCTO-PAK ................................................. 13
PROCTOSOL HC ........................................ 13
PROCTOZONE-HC ................................. 13
PROCYSBI ............................................................ 83
PRODIGY AUTOCODE BLOOD
GLUCOSE ............................................................. 73
PRODIGY CONTROL
SOLUTION ....................................................... 107
PRODIGY INSULIN PEN
NEEDLES ........................................................... 107
PRODIGY INSULIN SYRINGE
............................................................................................. 107
PRODIGY LANCETS 21G .......... 107
PRODIGY LANCING DEVICE
............................................................................................. 107
PRODIGY MINI PEN NEEDLES
............................................................................................. 107
PRODIGY NO CODING BLOOD
GLUC ........................................................................... 73
PRODIGY SAFETY LANCETS
26G ............................................................................... 107
PRODIGY SHORT PEN
NEEDLES ........................................................... 107
PRODIGY TWIST TOP
LANCETS 28G ............................................. 108
PRODRIN .......................................................... 116
PROFERRIN-FORTE ........................... 87
PROFILNINE SD ........................................ 84
progesterone ........................................................ 135
progesterone micronized ........................ 135
PROGLYCEM ................................................. 25
PROGRAF ............................................................ 44
PROLASTIN ................................................... 137
PROLASTIN-C ............................................ 137
PROLENSA ...................................................... 132
Index
PREMPHASE ................................................... 80
PREMPRO ............................................................ 80
prena1 pearl ......................................................... 122
prena1 plus/quatrefolic ............................ 122
prena1/quatrefolic ........................................ 122
prenaissance ........................................................ 122
prenaissance 90 dha .................................... 122
prenaissance balance ................................. 122
prenaissance dha ............................................ 122
prenaissance harmony dha .................. 123
prenaissance next .......................................... 123
prenaissance next-b ..................................... 123
prenaissance plus ........................................... 123
prenaissance promise ................................. 123
PRENATA ......................................................... 123
prenatabs fa ......................................................... 123
PRENATABS RX ..................................... 123
prenatal 19 ............................................................ 123
PRENATAL AD ........................................ 123
PRENATAL
MULTIVITAMIN-ULTRA ........ 123
prenatal plus iron ........................................... 123
prenatal+dha ...................................................... 123
PRENATAL-U ............................................. 123
PRENATE .......................................................... 123
PRENATE AM ............................................ 123
PRENATE DHA ........................................ 123
PRENATE ELITE .................................... 123
PRENATE ENHANCE ..................... 123
PRENATE ESSENTIAL ................. 123
PRENATE MINI ....................................... 123
PRENATE RESTORE ....................... 123
PRENEXA ......................................................... 123
PRENTIF CAVITY-RIM CERV
CAP .............................................................................. 107
PRENTIF FITTING SET ............... 107
PREPIDIL ........................................................... 134
PREPOPIK ............................................................ 89
PREQUE 10 ...................................................... 123
PRESTIGE GLUCOSE
CONTROL ......................................................... 107
prestige smart system test ....................... 73
PRESTIGE TEST ......................................... 73
PRESTIGE VALUE PACK ............. 73
PREVACID ....................................................... 140
PREVACID SOLUTAB .................... 140
PREVALITE ....................................................... 30
............................................................................................. 119
PLUS .......................................................................... 119
PREVIFEM .......................................................... 52
PREVPAC ........................................................... 140
PREZCOBIX ...................................................... 42
PREZISTA ............................................................. 42
PRIALT ........................................................................ 8
PRIFTIN .................................................................. 35
PRILOSEC ......................................................... 140
Index
Index
PRASCION FC ................................................ 63
PRASCION RA .............................................. 63
PRAVACHOL .................................................. 30
pravastatin sodium .......................................... 30
prazosin hcl .............................................................. 33
PRECISION GLUCOSE
CONTROL ......................................................... 107
PRECISION GLUCOSE
CONTROL SOLN .................................... 107
PRECISION GLUCOSE
KETONE CONTR ................................... 107
PRECISION
GLUCOSE/KETONE CONTR
............................................................................................. 107
PRECISION PCX ......................................... 73
PRECISION PCX PLUS TEST
................................................................................................ 73
PRECISION POINT OF CARE
TEST .............................................................................. 73
PRECISION QID TEST ....................... 73
PRECISION SOF-TACT TEST
................................................................................................ 73
PRECISION SUREDOSE PLUS
SYR .............................................................................. 107
PRECISION SURE-DOSE
SYRINGE ........................................................... 107
PRECISION THIN LANCETS
............................................................................................. 107
PRECISION THINS GP
LANCETS ........................................................... 107
PRECISION ULTRA LANCET
............................................................................................. 107
PRECISION XTRA BLOOD
GLUCOSE ............................................................. 73
PRECOSE ............................................................... 25
PRED FORTE ............................................... 131
PRED MILD ................................................... 131
PRED-G ................................................................ 131
PRED-G S.O.P. ............................................ 131
prednicarbate ......................................................... 63
prednisolone ............................................................ 54
prednisolone acetate ................................... 132
prednisolone sodium phosphate ......... 54
prednisone ................................................................. 54
prednisone (pak) .............................................. 54
PREDNISONE INTENSOL ........... 54
PREFERA OB ............................................... 122
PREFERA OB + DHA ....................... 122
PREFERAOB ONE ................................ 122
preferred plus glucose .................................. 25
preferred plus lancets colored .......... 107
preferred plus lancets thin ................... 107
preferred plus unifine pentips ........... 107
PREFEST ................................................................ 80
PREFOL-DHA ............................................. 122
PRE-FOLIC ......................................................... 87
PRELONE ............................................................. 54
PREMARIN .......................................... 80, 143
(Updated 07/01/15)
166
RAPAFLO ............................................................. 83
RAPAMUNE ..................................................... 45
RASUVO ..................................................................... 7
RAVICTI ................................................................. 78
RAYOS ...................................................................... 54
RAZADYNE ................................................... 137
RAZADYNE ER ....................................... 137
RE 10 WASH ...................................................... 64
READI-CAT ....................................................... 73
READI-CAT 2 .................................................. 73
reality lancets .................................................... 108
reality swabs ....................................................... 108
reality trigger lancets ................................ 108
reaphirm .................................................................. 123
REBETOL .............................................................. 42
REBIF ...................................................................... 137
REBIF REBIDOSE ................................. 137
REBIF REBIDOSE TITRATION
PACK ........................................................................ 137
REBIF TITRATION PACK ....... 137
RECLAST ............................................................... 78
RECLIPSEN ....................................................... 52
RECOMBINATE .......................................... 84
rectacort-hc ............................................................. 13
RECTIV ..................................................................... 13
REFUAH PLUS BLOOD
GLUCOSE TEST .......................................... 73
REFUAH PLUS GLUCOSE
CONTROL ......................................................... 108
REGENECARE ............................................. 64
REGLAN ................................................................ 81
REGRANEX ...................................................... 64
RELAGARD ................................................... 143
relcof c .......................................................................... 55
RELENZA DISKHALER ................. 42
RELHIST ................................................................ 55
RELION ALCOHOL SWABS
............................................................................................. 108
RELION BLOOD GLUCOSE
TEST .............................................................................. 73
RELION CONFIRM/MICRO
TEST .............................................................................. 73
RELION GLUCOSE ................................ 26
RELION GLUCOSE DRINK ...... 26
RELION INSULIN SYRINGE
............................................................................................. 108
RELI-ON INSULIN SYRINGE
............................................................................................. 108
RELION KETONE .................................... 74
RELION LANCETS
MICRO-THIN 33G ................................. 108
RELION LANCETS STANDARD
21G ............................................................................... 108
RELION LANCETS THIN 26G
............................................................................................. 109
RELION LANCETS
ULTRA-THIN 30G ................................ 109
Index
qc alcohol swabs ............................................. 108
qc insulin syringe ............................................ 108
qc lancets super thin 30g ....................... 108
qc lancets ultra thin ..................................... 108
qc pen needles .................................................... 108
qc unifine pentips ........................................... 108
QNASL ................................................................... 127
QNASL CHILDRENS ........................ 127
QUALAQUIN .................................................. 35
QUARTETTE ................................................... 52
QUASENSE ......................................................... 52
QUDEXY XR .................................................... 19
QUESTRAN ........................................................ 30
QUESTRAN LIGHT ............................... 30
quetiapine fumarate ....................................... 40
QUFLORA PEDIATRIC ............... 123
QUICKTEK CONTROL
SOLUTION ....................................................... 108
QUICKTEK TEST ...................................... 73
QUILLIVANT XR ......................................... 4
quinapril hcl ............................................................ 33
quinapril-hydrochlorothiazide ............ 33
quinidine gluconate er .................................. 15
quinidine sulfate ................................................. 15
quinine sulfate ....................................................... 35
QUINTET AC BLOOD
GLUCOSE TEST .......................................... 73
QUINTET BLOOD GLUCOSE
TEST .............................................................................. 73
QUINTET CONTROL
HIGH/NORMAL ...................................... 108
QUINZYME ........................................................... 5
QUTENZA ............................................................ 63
QUTENZA (2 PATCH) ........................ 64
QVAR ........................................................................... 16
ra alcohol swabs .............................................. 108
ra antifungal ........................................................... 64
RA E-ZJECT COLOR LANCETS
33G ............................................................................... 108
RA E-ZJECT LANCETS 28G ... 108
RA E-ZJECT LANCETS THIN
26G ............................................................................... 108
RA E-ZJECT LANCETS THIN
28G ............................................................................... 108
RA E-ZJECT LANCETS ULTRA
THIN ......................................................................... 108
ra glucose ................................................................... 25
ra lancing device ............................................. 108
ra niacin ................................................................... 144
ra no flush niacin ............................................ 144
ra pen needles ..................................................... 108
RA TRUETEST TEST ........................... 73
rabeprazole sodium ..................................... 141
RADIOGARDASE .................................... 27
raloxifene hcl ......................................................... 78
ramipril ........................................................................ 33
RANEXA ................................................................ 13
ranitidine hcl ....................................................... 141
Index
Index
PROLIA .................................................................... 78
PROMACTA ...................................................... 87
promethazine hcl ................................................ 29
promethazine-codeine .................................. 55
promethazine-dm ............................................... 55
PROMETHEGAN ...................................... 29
PROMETRIUM ......................................... 135
propafenone hcl ................................................... 14
propafenone hcl er ........................................... 14
proparacaine hcl ............................................. 132
proparacaine-fluorescein ....................... 132
propranolol hcl ..................................................... 46
propranolol hcl er ............................................. 46
propylthiouracil ............................................... 138
PROSCAR .............................................................. 83
PROSTIN E2 ................................................... 134
PROTECTIRON ............................................ 87
PROTHELIAL .............................................. 119
PROTONIX ...................................................... 140
PROTOPIC ........................................................... 63
protriptyline hcl .................................................. 21
PROVENTIL HFA ..................................... 16
PROVERA ......................................................... 135
PROVIDA OB ................................................ 123
PROVIGIL ................................................................ 4
PROVOCHOLINE ...................................... 73
PROZAC .................................................................. 21
PROZAC WEEKLY ................................. 21
PRUDOXIN ........................................................ 63
pseudoeph-bromphen-dm ......................... 55
PSS SELECT GP LANCETS ...... 108
PSS SELECT PLATFORMS ...... 108
PSS SELECT SAFETY LANCETS
............................................................................................. 108
PTS PANELS GLUCOSE TEST
................................................................................................ 73
PULMICORT .................................................... 16
PULMICORT FLEXHALER ...... 16
PULMOSAL ........................................................ 55
PULMOZYME ............................................. 137
purefe ob plus ..................................................... 123
purefe plus ................................................................. 87
purevit dualfe plus ............................................ 87
PURINETHOL ................................................ 37
px advanced lancing device ................ 108
px extra short pen needles ................... 108
px glucose .................................................................. 25
px insulin syringe ........................................... 108
px lancet auto injector ............................. 108
px lancets ................................................................ 108
px lancets ultra thin .................................... 108
px niacin .................................................................. 144
px pen needle ...................................................... 108
px shortlength pen needles .................. 108
PYLERA ............................................................... 140
pyrazinamide ......................................................... 35
pyridostigmine bromide ............................. 35
qc advanced lancing device ................. 108
(Updated 07/01/15)
167
109
RELION MINI PEN NEEDLES
............................................................................................. 109
RELION PEN NEEDLES .............. 109
RELION PRIME TEST ........................ 74
RELION SHORT PEN NEEDLES
............................................................................................. 109
RELION ULTIMA TEST .................. 74
RELION ULTRA THIN
LANCETS 30G ............................................. 109
RELION ULTRA THIN PLUS
LANCETS ........................................................... 109
RELISTOR ............................................................ 81
relnate dha ............................................................ 123
RELPAX ............................................................... 116
REMEDY ANTIFUNGAL ............. 64
REMERON .......................................................... 21
REMERON SOLTAB ............................. 21
REMEVEN ........................................................... 64
REMICADE ........................................................ 81
REMODULIN .................................................. 48
RENACIDIN ..................................................... 83
RENAGEL ............................................................ 81
RENAL ................................................................... 123
RENALPREN ............................................... 123
RENATABS ..................................................... 123
RENATABS WITH IRON ............ 123
rena-vite rx ........................................................... 123
RENAX .................................................................. 124
RENEW ADV CARTRIDGE
REFILLS .............................................................. 109
RENEW ADVANCED
LANCING DEVICE ............................. 109
reno caps ................................................................. 124
RENVELA ............................................................. 81
repaglinide ................................................................ 26
repan ................................................................................... 8
replacement air filter ................................. 109
replacement filters ........................................ 109
REPREXAIN ..................................................... 10
REQUIP .................................................................... 38
REQUIP XL ........................................................ 38
RESCON-JR ........................................................ 55
RESCON-MX .................................................... 55
RESCRIPTOR .................................................. 42
RESCULA .......................................................... 132
RESECTISOL .................................................... 83
RESPA-BR ............................................................ 29
RESTASIS .......................................................... 132
RESTORIL ............................................................ 88
RETIN-A ................................................................. 64
RETIN-A MICRO ....................................... 64
RETIN-A MICRO PUMP ................. 64
RETROVIR .......................................................... 42
REVATIO ............................................................... 48
REVEAL BLOOD GLUCOSE
TEST .............................................................................. 74
.............................................................................................
ROBINUL-FORTE ................................ 141
ROCALTROL ................................................... 78
ROMILAR AC ................................................. 56
romycin ..................................................................... 132
ropinirole hcl .......................................................... 38
ropinirole hcl er ................................................... 39
ROSADAN ........................................................... 64
ROSANIL CLEANSER ....................... 64
ROSE GLO ........................................................ 132
ROXICET ..................................................... 10, 11
ROXICODONE .............................................. 11
ROZEREM ........................................................... 88
RUCONEST ........................................................ 85
RYTARY ................................................................ 39
RYTHMOL .......................................................... 15
RYTHMOL SR ................................................ 15
SABRIL ..................................................................... 19
SAFESNAP INSULIN SYRINGE
............................................................................................. 109
SAFE-T-LANCE ........................................ 109
SAFE-T-LANCE PLUS .................... 109
safety lancet 21g/pressure act ......... 109
safety lancet 28g/pressure act ......... 109
SAFETY LANCET 2MM ............... 109
SAFETY LANCETS ............................. 109
SAFETY LANCETS 21G ............... 109
safety lancets 28g .......................................... 109
SAFETY LET LANCETS .............. 109
SAFETY SEAL LANCETS .......... 109
SAFETY-GLIDE SYRINGE ..... 109
SAFYRAL ............................................................. 52
SAIZEN ..................................................................... 78
SAIZEN CLICK.EASY ........................ 78
SALACYN ............................................................. 64
SALAGEN ......................................................... 119
SALICEPT .......................................................... 119
salicylic acid ........................................................... 64
salicylic acid wart remover .................... 64
SALKERA ............................................................. 64
salsalate .......................................................................... 8
SALVAX DUO PLUS ............................. 64
SAMI THE SEAL FILTERS ...... 109
SAMSCA .................................................................. 78
SANCTURA .................................................... 142
SANCUSO ............................................................. 27
SANDIMMUNE ........................................... 45
SANDOSTATIN ............................................ 78
SANDOSTATIN LAR DEPOT
................................................................................................ 78
SANTYL .................................................................. 64
SAPHRIS ................................................................. 40
SARAFEM ......................................................... 137
SAVAYSA .............................................................. 17
SAVELLA ........................................................... 137
SAVELLA TITRATION PACK
............................................................................................. 137
sb alcohol prep .................................................. 109
sb lancets thin .................................................... 109
Index
revesta ........................................................................... 87
REVIA ......................................................................... 27
REVINA ................................................................... 64
REVLIMID ........................................................... 45
REXALL BLOOD GLUCOSE
TEST .............................................................................. 74
REXALL LANCETS ULTRA
THIN 30G ........................................................... 109
REYATAZ ............................................................. 43
REZIRA .................................................................... 56
RHEUMATREX .............................................. 7
RHINOCORT AQUA ......................... 127
RIASTAP ................................................................ 84
RIAX ............................................................................. 64
RIBASPHERE .................................................. 43
RIBATAB ............................................................... 43
ribavirin ....................................................................... 43
RIDAURA ................................................................ 7
RIFADIN ................................................................ 35
RIFAMATE ......................................................... 35
rifampin ....................................................................... 35
RIFATER ............................................................... 35
RIGHTEST ALTERNATE SITE
ADAPT ................................................................... 109
RIGHTEST GC300 CONTROL
............................................................................................. 109
RIGHTEST GD500 LANCING
DEVICE ................................................................. 109
RIGHTEST GL300 LANCETS
............................................................................................. 109
RIGHTEST GS100 BLOOD
GLUCOSE ............................................................. 74
GLUCOSE ............................................................. 74
GLUCOSE ............................................................. 74
RILUTEK ........................................................... 128
riluzole ....................................................................... 128
rimantadine hcl .................................................... 43
ringers irrigation ................................................ 45
RIOMET .................................................................. 26
risedronate sodium .......................................... 78
RISPERDAL ...................................................... 40
RISPERDAL M-TAB .............................. 40
risperidone ................................................................ 40
RISPERIDONE M-TAB ..................... 40
RITALIN .................................................................... 4
RITALIN LA ......................................................... 5
RITALIN SR .......................................................... 5
RITEFLO ............................................................. 109
rivastigmine tartrate .................................. 137
rixubis ............................................................................ 85
rizatriptan benzoate ................................... 116
R-NATAL OB ................................................ 124
robafen ac .................................................................. 56
ROBAXIN .......................................................... 127
ROBAXIN-750 .............................................. 127
ROBINUL ........................................................... 141
Index
Index
RELION LANCING DEVICE
(Updated 07/01/15)
168
SMARTEST BLOOD GLUCOSE
TEST .............................................................................. 74
SMARTEST CONTROL
MEDIUM ............................................................ 110
SMARTEST LANCETS 28G ..... 110
smz-tmp ds ................................................................ 34
sodium chloride ......................................... 56, 83
sodium fluoride ................................................. 118
sodium hyaluronate ........................................ 65
sodium phenylbutyrate ................................ 78
sodium polystyrene sulfonate .............. 45
sodium sulfacetamide ................................... 65
sodium sulfacetamide wash .................... 65
SOJOURN .............................................................. 82
SOLARAZE ......................................................... 65
SOLARTEK GLUCOSE
CONTROL ......................................................... 110
SOLIA .......................................................................... 52
SOLIRIS ................................................................... 85
SOLODYN ......................................................... 138
SOLTAMOX ....................................................... 37
SOLUS V2 CONTROL ...................... 110
SOLUS V2 LANCETS 28G .......... 110
SOLUS V2 LANCING DEVICE
............................................................................................. 110
SOLUS V2 TEST ........................................... 74
SOLUS V2 TWIST LANCETS
30G ............................................................................... 110
SOMA ....................................................................... 127
SOMATULINE DEPOT ..................... 78
SOMAVERT ....................................................... 78
SONATA .................................................................. 88
SOOLANTRA ................................................... 65
SOOTHE & COOL INZO
ANTIFUNGAL .............................................. 65
SORIATANE ..................................................... 65
SORILUX ............................................................... 65
SORINE .................................................................... 46
sotalol hcl ................................................................... 46
sotalol hcl (af) .................................................... 46
SOTYLIZE ............................................................ 46
SOVALDI ............................................................... 43
SPECTRACEF ................................................. 48
SPIRIVA HANDIHALER ................ 16
SPIRIVA RESPIMAT ............................ 16
spironolactone ...................................................... 76
spironolactone-hctz ......................................... 76
SPORANOX ........................................................ 28
SPORANOX PULSEPAK ................. 28
SPRINTEC 28 .................................................... 52
SPRIX .............................................................................. 7
SPRYCEL ............................................................... 37
SPS .................................................................................... 45
SRONYX ................................................................. 52
SSD .................................................................................. 65
SSD AF ....................................................................... 65
SSKI ............................................................................ 118
sss 10-5 ......................................................................... 65
Index
SIDESTREAM PLS ADULT
FACE MASK .................................................. 110
SIGNIFOR ............................................................ 78
SIGNIFOR LAR ........................................... 78
sildenafil citrate .................................................. 48
SILENOR ................................................................ 88
silicone mask/adult ...................................... 110
silicone mask/infant .................................... 110
silicone mask/pediatric ............................ 110
SILVADENE ...................................................... 64
silver sulfadiazine ............................................. 64
SIMBRINZA ................................................... 132
SIMCOR ................................................................... 30
SIMPLE DIAGNOSTICS
LANCING DEV ......................................... 110
SIMPONI .................................................................... 7
SIMULECT .......................................................... 45
simvastatin ............................................................... 30
SINEMET ............................................................... 39
SINEMET CR ................................................... 39
SINGLE-LET ................................................. 110
SINGULAIR ...................................................... 16
sirolimus ...................................................................... 45
SIRTURO ............................................................... 36
SITZMARKS ..................................................... 74
SIVEXTRO ........................................................... 34
SKELAXIN ....................................................... 127
SKELID ..................................................................... 78
SKLICE ..................................................................... 64
SKYLA ....................................................................... 52
SLO-NIACIN .................................................. 144
sm alcohol prep ................................................ 110
sm antifungal miconazole ........................ 64
sm glucose ................................................................. 26
sm lancets 21g ................................................... 110
sm lancets 33g ................................................... 110
sm niacin cr .......................................................... 144
sm super thin lancets 30g ...................... 110
sm thin lancets 26g ...................................... 110
SMART DIABETES VANTAGE
LANCETS ........................................................... 110
SMART DIABETES VANTAGE
LANCING .......................................................... 110
SMART DIABETES XPRES
TEST .............................................................................. 74
SMART SENSE COLOR
LANCETS 33G ............................................. 110
SMART SENSE GLUCOSE .......... 26
SMART SENSE PREMIUM
TEST .............................................................................. 74
SMART SENSE STANDARD
LANCETS ........................................................... 110
SMART SENSE SUPER THIN
LANCETS ........................................................... 110
SMART SENSE THIN LANCETS
26G ............................................................................... 110
SMART SENSE VALUE TEST
................................................................................................ 74
Index
Index
sb lancets ultra thin ..................................... 109
scalacort ...................................................................... 64
SCLEROSOL INTRAPLEURAL
............................................................................................. 137
se 10-5 ss ..................................................................... 64
SEASONIQUE ................................................. 52
SEB-PREV ............................................................. 64
SEB-PREV WASH ...................................... 64
SECONAL ............................................................. 88
SECTRAL ............................................................... 46
SECURA ANTIFUNGAL ............... 64
SECURA ANTIFUNGAL
EXTRA THICK .............................................. 64
select-lite device/lancets ......................... 109
select-lite lancing device ........................ 109
SELECT-OB ..................................................... 124
SELECT-OB+DHA ................................ 124
selegiline hcl ............................................................ 39
selenium sulfide ................................................... 64
SELRX ........................................................................ 64
SELZENTRY ..................................................... 43
SEMPREX-D ..................................................... 56
se-natal 19 ............................................................. 124
SENSIPAR ............................................................ 78
SENTRAVIL PM-25 ................................. 22
sentry test .................................................................. 74
SEPTRA DS ......................................................... 34
SEREVENT DISKUS ............................. 16
SEROPHENE .................................................... 78
SEROQUEL ......................................................... 40
SEROQUEL XR ............................................ 40
SEROSTIM ........................................................... 78
sertraline hcl ........................................................... 22
se-tan plus ................................................................. 87
sevoflurane ............................................................... 82
sf ....................................................................................... 119
sf 5000 plus ........................................................... 119
SFROWASA ........................................................ 82
SHOPKO ALCOHOL SWABS
............................................................................................. 109
SHOPKO AUTOLET LANCING
DEVICE ................................................................. 109
SHOPKO ON-THE-GO
LANCETS 30G ............................................. 110
SHOPKO UNIFINE PENTIPS
............................................................................................. 110
SHOPKO UNILET LANCETS
28G ............................................................................... 110
SHOPKO UNILET LANCETS
30G ............................................................................... 110
shoprite test ............................................................. 74
SHUR-SEAL CONTRACEPTIVE
............................................................................................. 143
SIDESTREAM ADULT FACE
MASK ...................................................................... 110
SIDESTREAM PEDIATRIC
FACE MASK .................................................. 110
(Updated 07/01/15)
169
SYNAREL ............................................................. 78
SYNATEK ......................................................... 124
SYNERA .................................................................. 65
SYNTHROID ................................................ 138
SYNVISC ONE ............................................ 127
SYPRINE ................................................................ 45
T.R.U.E. TEST ................................................. 74
TABLOID ............................................................... 37
TACLONEX ....................................................... 65
tacrolimus ....................................................... 45, 65
TAFINLAR .......................................................... 37
TAGITOL V ........................................................ 74
tai doc control ................................................... 111
TAMIFLU ............................................................. 43
tamoxifen citrate ............................................... 37
tamsulosin hcl ....................................................... 83
TANDEM DHA .......................................... 124
TANDEM F ......................................................... 87
TANDEM OB ................................................ 124
TANZEUM .......................................................... 26
TAPAZOLE ...................................................... 138
TARCEVA ............................................................. 37
TARGRETIN .......................................... 37, 65
TARKA ..................................................................... 33
TARON EC CALCIUM ................... 124
taron forte ................................................................. 87
TARON-BC ...................................................... 124
TARON-C DHA ......................................... 124
TARON-CRYSTALS .............................. 83
TARON-PREX ............................................. 124
TASIGNA ............................................................... 37
TASMAR ................................................................ 39
TAZORAC ............................................................ 66
TAZTIA XT ......................................................... 47
tbc ...................................................................................... 66
TECFIDERA .................................................. 137
TECHLITE AST LANCETS ...... 111
TECHLITE LANCETS ..................... 111
TECHLITE LANCETS 30G ....... 111
TEGRETOL ......................................................... 19
TEGRETOL-XR ............................................ 19
TEKAMLO ........................................................... 33
TEKTURNA ...................................................... 33
TEKTURNA HCT ...................................... 33
TELCARE BLOOD GLUCOSE
TEST .............................................................................. 74
TELCARE GLUCOSE
CONTROL ......................................................... 111
temazepam ............................................................... 88
TEMODAR .......................................................... 37
TEMOVATE ....................................................... 66
TEMOVATE E ................................................. 66
temozolomide ........................................................ 37
TENCON .................................................................... 8
TENEX ....................................................................... 33
TENORETIC 100 .......................................... 33
TENORETIC 50 ............................................. 33
TENORMIN ....................................................... 46
Index
sure comfort lancets 28g ....................... 110
sure comfort lancets 30g ....................... 110
sure comfort lancing pen ....................... 111
sure comfort pen needles ....................... 111
SURE EDGE GLUCOSE
CONTROL ......................................................... 111
SURE EDGE TEST ................................... 74
SURECHEK BLOOD GLUCOSE
TEST .............................................................................. 74
SURECHEK CONTROL
SOLUTION ....................................................... 111
SURE-FINE PEN NEEDLES ... 111
SURE-JECT INSULIN SYRINGE
............................................................................................. 111
SURE-LANCE FLAT LANCETS
............................................................................................. 111
SURE-LANCE LANCETS 26G
............................................................................................. 111
SURE-LANCE THIN LANCETS
28G ............................................................................... 111
SURE-LANCE ULTRA THIN
LANCETS ........................................................... 111
SURELITE LANCETS ...................... 111
SURE-PEN ........................................................ 111
SURE-PREP ALCOHOL PREP
............................................................................................. 111
SURESTEP GLUCOSE
CONTROL ......................................................... 111
SURESTEP PRO HIGH
GLUCOSE .......................................................... 111
SURESTEP PRO LOW
GLUCOSE .......................................................... 111
SURESTEP PRO NORMAL
GLUCOSE .......................................................... 111
SURESTEP PRO TEST ........................ 74
SURESTEP TEST ........................................ 74
SURE-TEST EASYPLUS
CONTROL ......................................................... 111
SURE-TEST EASYPLUS MINI
TEST .............................................................................. 74
SURE-TOUCH LANCETS
UNIVERSAL .................................................. 111
SURMONTIL ................................................... 22
SUSTIVA ................................................................. 43
SUTENT ................................................................... 37
SYEDA ....................................................................... 52
SYMAX DUOTAB ................................. 141
SYMAX FASTABS ................................ 141
SYMAX-SL ....................................................... 141
SYMAX-SR ...................................................... 141
SYMBICORT ..................................................... 16
SYMBYAX ........................................................ 137
SYMLINPEN 120 ......................................... 26
SYMLINPEN 60 ............................................ 26
SYNAGEX ......................................................... 124
SYNAGIS ............................................................ 135
SYNALAR ............................................................ 65
SYNALGOS-DC ............................................ 11
Index
Index
ST JOSEPH ASPIRIN ................................ 8
STALEVO 100 ................................................... 39
STALEVO 125 ................................................... 39
STALEVO 150 ................................................... 39
STALEVO 200 ................................................... 39
STALEVO 50 ...................................................... 39
STALEVO 75 ...................................................... 39
stannous fluoride ............................................ 119
STARLIX ................................................................ 26
stavudine ..................................................................... 43
STAVZOR .............................................................. 19
STELARA .............................................................. 65
STERILANCE PA ................................... 110
STERILANCE TL .................................... 110
STERILE TALC POWDER ........ 137
sterile water for irrigation ....................... 45
STIMATE ............................................................... 78
STIVARGA .......................................................... 37
STRATTERA ........................................................ 5
STRIANT ................................................................ 12
STRIBILD .............................................................. 43
STRIVERDI RESPIMAT .................. 16
STROMECTOL .............................................. 13
STROVITE FORTE ............................... 124
SUBOXONE ........................................................ 11
SUBSYS ..................................................................... 11
SUCLEAR ............................................................. 89
SUCRAID .............................................................. 75
sucralfate ................................................................ 141
SULAR ....................................................................... 47
sulfacetamide sodium ...................... 65, 132
sulfacetamide sodium (acne) .............. 65
sulfacetamide sodium-sulfur ................. 65
sulfacetamide sod-sulfur wash ............ 65
sulfacetamide-prednisolone ................ 132
SULFACLEANSE 8/4 ............................ 65
sulfamethoxazole-tmp ds ......................... 34
sulfamethoxazole-trimethoprim ....... 35
SULFAMYLON ............................................ 65
sulfasalazine ........................................................... 82
SULFATRIM PEDIATRIC ............ 35
SULFAZINE ...................................................... 82
SULFAZINE EC ........................................... 82
SULFOAM ............................................................ 65
sulindac ............................................................................ 7
sumatriptan succinate ............................... 116
SUMAVEL DOSEPRO ..................... 116
super thin lancets ........................................... 110
SUPERVITE EC ......................................... 124
SUPHERA ............................................................. 65
SUPPRELIN LA ............................................ 78
SUPRANE ............................................................. 82
SUPRAX .................................................................. 48
supreme ii high/low control ................ 110
SUPREME TEST .......................................... 74
SUPREP BOWEL PREP ..................... 89
sure comfort alcohol prep ..................... 110
sure comfort insulin syringe ............... 110
(Updated 07/01/15)
170
topiramate ................................................................ 19
TOPROL XL ....................................................... 46
torsemide .................................................................... 76
TOUJEO SOLOSTAR ............................ 26
TRACLEER ......................................................... 48
TRADJENTA .................................................... 26
tramadol hcl ............................................................ 11
tramadol hcl er ..................................................... 11
tramadol hcl er (biphasic) ..................... 11
tramadol-acetaminophen .......................... 11
TRANDATE ....................................................... 46
trandolapril .............................................................. 33
trandolapril-verapamil hcl er ............... 33
tranexamic acid .................................................. 88
TRANXENE-T ................................................ 14
tranylcypromine sulfate ............................. 22
TRAVATAN Z ............................................. 132
travoprost ............................................................... 132
trazodone hcl .......................................................... 22
TRECATOR ........................................................ 36
TRELSTAR MIXJECT ......................... 37
tretinoin ............................................................. 38, 66
tretinoin microsphere .................................... 66
tretinoin microsphere pump ................... 66
TRETIN-X ............................................................. 66
TRETTEN .............................................................. 85
TREXALL ............................................................. 38
TREXIMET ...................................................... 116
TREZIX ..................................................................... 11
TRI RX ................................................................... 124
triadvance ............................................................... 124
triamcinolone acetonide ............... 66, 119
triamterene-hctz ................................................. 76
TRIANEX .............................................................. 66
triazolam .................................................................... 89
TRIBENZOR ..................................................... 33
TRICARE PRENATAL
COMPLEAT .................................................... 124
TRICARE PRENATAL DHA
ONE ............................................................................ 124
TRI-CHLOR ....................................................... 66
TRICODE AR .................................................. 56
TRICON ................................................................... 87
TRICOR ................................................................... 30
TRIDERM ............................................................. 66
TRI-ESTARYLLA ...................................... 52
trifluoperazine hcl ............................................ 41
trifluridine .............................................................. 132
trigels-f forte .......................................................... 87
TRIGLIDE ............................................................ 30
trihexyphenidyl hcl .......................................... 39
TRI-LEGEST FE .......................................... 52
TRILEPTAL ....................................................... 19
TRI-LINYAH .................................................... 53
TRILIPIX ................................................................ 30
TRILYTE ................................................................ 89
trimethobenzamide hcl ................................ 27
trimethoprim .......................................................... 35
Index
THYROLAR-1/4 ........................................ 138
THYROLAR-2 ............................................. 139
THYROLAR-3 ............................................. 139
tiagabine hcl ........................................................... 19
TIAZAC .................................................................... 47
ticlopidine hcl ........................................................ 85
TIGAN ........................................................................ 27
TIKOSYN ............................................................... 15
TILIA FE ................................................................. 52
timolol maleate ................................................ 132
TIMOPTIC ......................................................... 132
TIMOPTIC OCUDOSE .................... 132
TIMOPTIC-XE ............................................. 132
TINDAMAX ...................................................... 35
tinidazole .................................................................... 35
TIROSINT .......................................................... 139
TISSEEL VH ....................................................... 88
TISSEEL VHSD .............................................. 88
TIS-U-SOL ............................................................. 45
TIVICAY ................................................................. 43
TIVORBEX .............................................................. 7
tizanidine hcl ....................................................... 127
tl gard rx ..................................................................... 87
TL G-FOL OS ................................................ 124
tl icon .............................................................................. 87
tl urea ............................................................................. 66
tl-assure one ........................................................ 124
tl-care dha .............................................................. 124
tl-fluorivite ............................................................ 124
tl-select ...................................................................... 124
tl-select dha .......................................................... 124
TOBI .................................................................................. 5
TOBI PODHALER ........................................ 5
TOBRADEX .................................................... 132
TOBRADEX ST .......................................... 132
tobramycin ..................................................... 5, 132
tobramycin-dexamethasone ............... 132
tobrasol ..................................................................... 132
TOBREX ............................................................... 132
TODAY SPONGE .................................... 143
todays health lancing device .............. 112
todays health mini pen needles ....... 112
todays health pen needles ..................... 112
todays health short pen needle ........ 112
todays health thin lancets 28g ......... 112
todays health thin lancets 30g ......... 112
TOFRANIL .......................................................... 22
TOFRANIL-PM ............................................. 22
tolazamide ................................................................ 26
tolcapone .................................................................... 39
tolmetin sodium ...................................................... 7
tolterodine tartrate er ............................... 142
TOPAMAX ........................................................... 19
TOPAMAX SPRINKLE ..................... 19
topcare clickfine pen needles ............ 112
TOPICORT ........................................................... 66
TOPICORT SPRAY .................................. 66
TOPIRAGEN ..................................................... 19
Index
Index
TERAZOL 3 ..................................................... 143
TERAZOL 7 ..................................................... 143
terazosin hcl ............................................................ 33
terbinafine hcl ....................................................... 28
terbutaline sulfate ............................................ 16
terconazole ............................................................ 143
TERRELL .............................................................. 82
TERSI ........................................................................... 66
TERUMO INSULIN SYRINGE
............................................................................................. 111
TERUMO SURGUARD
INSULIN SYR .............................................. 111
TESSALON PERLES .............................. 56
TESTIM ..................................................................... 12
testosterone ............................................................. 12
TESTRED ............................................................... 12
TETCAINE ....................................................... 132
tetracaine hcl ...................................................... 132
tetracycline hcl ................................................. 138
TETRAVISC .................................................... 132
TETRAVISC FORTE .......................... 132
TEVETEN .............................................................. 33
TEVETEN HCT ............................................. 33
TEV-TROPIN .................................................... 78
TEXACORT ........................................................ 66
tgq 30pse/150gfn/15dm .............................. 56
tgq 30pse/3brm/15dm ................................... 56
tgt advanced lancing device ................ 111
tgt alcohol swabs ............................................ 111
tgt blood glucose test .................................... 74
tgt glucose ................................................................. 26
tgt lancet alternate site ........................... 111
tgt lancet micro thin 33g ....................... 111
tgt lancet super thin 30g ........................ 111
tgt lancet thin 23g ......................................... 111
tgt lancet thin 26g ......................................... 111
tgt lancet ultra thin 28g .......................... 111
tgt lancet ultra thin 30g .......................... 112
tgt lancing device ........................................... 112
THALOMID ....................................................... 45
THEO-24 .................................................................. 16
THEOCHRON ................................................. 16
theophylline ............................................................. 16
theophylline er ...................................................... 16
THERABENZAPRINE-90-5 ...... 127
THERMAZENE ............................................ 66
THINLETS GP LANCETS .......... 112
THINLETS LANCET ......................... 112
THINPRO INSULIN SYRINGE
............................................................................................. 112
THIOLA ................................................................... 83
thioridazine hcl .................................................... 40
thiothixene ................................................................ 40
THRESHOLD IMT ................................ 112
THYMOGLOBULIN .............................. 45
THYROGEN ...................................................... 74
THYROLAR-1 ............................................. 138
THYROLAR-1/2 ........................................ 138
(Updated 07/01/15)
171
............................................................................................. 113
SHORT ................................................................... 113
ULTILET LANCETS .......................... 113
ULTILET OPERATING DEVICE
............................................................................................. 113
ULTILET SAFETY LANCETS
23G ............................................................................... 113
ULTILET ULTI-LANCE ADJ
DEVICE ................................................................. 113
ULTIMA TEST ............................................... 74
ultimatecare advantage ........................... 125
ultimatecare combo ..................................... 125
ultra comfort insulin syringe ............. 113
ULTRA NATALCARE .................... 125
ultra tabs ................................................................. 125
ultra thin lancets 28g ................................. 113
ultra thin lancets 30g ................................. 113
ULTRACET ........................................................ 11
ULTRALANCE .......................................... 113
ULTRAM ............................................................... 11
ULTRAM ER .................................................... 11
ULTRA-THIN II AUTO
LANCET ............................................................... 113
ULTRA-THIN II INS SYR
SHORT ................................................................... 113
ULTRA-THIN II INSULIN
SYRINGE ........................................................... 113
ULTRA-THIN II LANCETS ..... 113
ULTRA-THIN II MINI PEN
NEEDLE ............................................................... 113
ULTRA-THIN II PEN NEEDLE
SHORT ................................................................... 113
ULTRA-THIN II PEN NEEDLES
............................................................................................. 113
ULTRATRAK PRO CONTROL
............................................................................................. 113
ULTRATRAK PRO TEST .............. 74
ULTRATRAK ULTIMATE
CONTROL ......................................................... 113
ULTRATRAK ULTIMATE TEST
................................................................................................ 74
ULTRAVATE ................................................... 66
ULTRESA .............................................................. 75
UMECTA ................................................................ 66
UMECTA PD .................................................... 66
UNIFINE PENTIPS .............................. 113
unifine pentips plus ...................................... 113
UNILET COMFORTOUCH
LANCET ............................................................... 113
UNILET EXCELITE ........................... 113
UNILET EXCELITE II ..................... 113
UNILET G.P. LANCET ................... 113
UNILET G.P. SUPERLITE
LANCET ............................................................... 113
UNILET GP 28 ULTRA THIN
............................................................................................. 113
Index
TRUZONE PEAK FLOW
METER .................................................................. 112
tubing/wing tip .................................................. 112
TUDORZA PRESSAIR ....................... 16
TUSNEL ................................................................... 56
tusnel ped-c .............................................................. 56
TUSSICAPS ......................................................... 56
TUSSIGON ........................................................... 56
TUSSIONEX PENNKINETIC ER
................................................................................................ 56
TUSSO-DMR ..................................................... 56
TWINJECT ....................................................... 143
TYBOST ................................................................... 43
TYKERB .................................................................. 38
................................................................................................ 11
................................................................................................ 11
TYSABRI ............................................................. 137
TYVASO .................................................................. 48
TYVASO REFILL ....................................... 48
TYVASO STARTER ................................ 48
TYZEKA .................................................................. 43
TYZINE ................................................................. 127
UCERIS .......................................................... 13, 54
U-CORT ................................................................... 66
UDAMIN SP ................................................... 125
U-KERA E ............................................................. 66
ULESFIA ................................................................ 66
ULORIC ................................................................... 83
ULTANE ................................................................. 82
ULTICARE INSULIN SAFETY
SYR .............................................................................. 112
ULTICARE INSULIN SYRINGE
............................................................................................. 112
ULTICARE MICRO PEN
NEEDLES ........................................................... 112
ULTICARE MINI PEN
NEEDLES ........................................................... 112
ULTICARE PEN NEEDLES .... 112
ULTICARE SHORT PEN
NEEDLES ........................................................... 113
ULTICARE THIN LANCETS
30G ............................................................................... 113
ULTI-LANCE AUTO-ADJUST
DEVICE ................................................................. 113
ULTI-LANCE AUTOMATIC
............................................................................................. 113
ULTI-LANCE MINI
ADJUSTABLE ............................................. 113
ultilet alcohol swab ...................................... 113
ultilet alcohol swabs ................................... 113
ULTILET BASIC LANCETS 30G
............................................................................................. 113
ULTILET CLASSIC LANCETS
............................................................................................. 113
ultilet glucose ......................................................... 26
Index
Index
trinatal gt ............................................................... 124
trinatal ultra ........................................................ 124
TRINATE ............................................................ 124
TRINESSA (28) ............................................... 53
TRI-NORINYL (28) .................................. 53
triphrocaps ............................................................ 124
triple antibiotic ................................................. 132
triple-vitamin/fluoride .............................. 124
TRI-PREVIFEM ........................................... 53
TRI-SPRINTEC ............................................. 53
tri-tabs dha ........................................................... 124
TRIUMEQ ............................................................. 43
TRIVEEN-DUO DHA ....................... 124
TRIVEEN-ONE .......................................... 124
TRIVEEN-PRX RNF .......................... 124
TRIVEEN-TEN ........................................... 124
TRIVEEN-U .................................................... 124
TRI-VI-FLOR ................................................ 124
tri-vi-floro .............................................................. 125
tri-vit/fluoride .................................................... 125
tri-vit/fluoride/iron ....................................... 125
tri-vitamin/fluoride ...................................... 125
TRIVORA (28) ................................................. 53
TRIZIVIR ............................................................... 43
TROKENDI XR ............................................ 19
tropicamide ........................................................... 132
trospium chloride ........................................... 142
trospium chloride er .................................... 142
true care test strip pack ............................. 74
TRUE METRIX BLOOD
GLUCOSE TEST .......................................... 74
TRUECONTROL GLUCOSE
CONT LEV 0 ................................................... 112
TRUECONTROL GLUCOSE
CONT LEV 1 ................................................... 112
TRUEDRAW LANCING
DEVICE ................................................................. 112
TRUEPLUS INSULIN SYRINGE
............................................................................................. 112
TRUEPLUS LANCETS 26G ..... 112
TRUEPLUS SAFETY LANCETS
28G ............................................................................... 112
............................................................................................. 112
............................................................................................. 112
............................................................................................. 112
TRUETEST TEST ....................................... 74
TRUETRACK GLUCOSE
CONTROL ......................................................... 112
TRUETRACK TEST ............................... 74
TRULICITY ....................................................... 26
TRUSOPT ........................................................... 132
TRUVADA ........................................................... 43
(Updated 07/01/15)
172
VERSACLOZ .................................................... 41
VERSICLEAR .................................................. 67
VESICARE ........................................................ 142
VESTURA ............................................................. 53
VEXOL ................................................................... 132
VFEND ...................................................................... 28
VIBRAMYCIN ............................................ 138
VICODIN ................................................................ 11
VICODIN ES ...................................................... 11
VICODIN HP .................................................... 11
VICOPROFEN ................................................ 11
VICTORY AGM-4000 TEST ......... 75
VICTORY CONTROL LEVEL 1/2
............................................................................................. 114
VICTOZA ............................................................... 26
VICTRELIS .......................................................... 43
VIDA MIA AUTOLET
LANCING DEV ......................................... 114
VIDA MIA UNIFINE PENTIPS
............................................................................................. 114
VIDA MIA UNILET LANCETS
28G ............................................................................... 114
VIDA MIA UNILET LANCETS
30G ............................................................................... 114
VIDEX ........................................................................ 43
VIDEX EC ............................................................. 43
VIEKIRA PAK ................................................ 43
VIGAMOX ........................................................ 132
VIIBRYD ................................................................ 22
VIMIZIM ................................................................ 78
VIMOVO ..................................................................... 7
VIMPAT ................................................................... 19
VINACAL ........................................................... 125
VINACAL B ..................................................... 125
VINATE AZ EXTRA ........................... 125
VINATE CALCIUM ............................ 125
VINATE DHA RF ................................... 125
VINATE GT ..................................................... 125
VINATE IC ....................................................... 125
VINATE II .......................................................... 125
VINATE M ........................................................ 125
vinate ultra ............................................................ 125
VIOKACE .............................................................. 75
viorele ............................................................................. 53
VIRACEPT ........................................................... 43
VIRAMUNE ....................................................... 43
VIRAMUNE XR ........................................... 43
VIRAZOLE .......................................................... 43
VIREAD ................................................................... 43
VIROPTIC .......................................................... 132
virt-bal dha ........................................................... 125
virt-bal dha plus .............................................. 125
virt-caps ................................................................... 125
virti-sulf ....................................................................... 67
virt-pn ......................................................................... 125
virt-pn dha ............................................................. 125
virt-pn plus ............................................................ 125
virt-select ................................................................ 125
Index
VAGIFEM .......................................................... 143
valacyclovir hcl .................................................... 43
VALCHLOR ....................................................... 67
VALCYTE ............................................................. 43
valganciclovir hcl ............................................... 43
VALIUM .................................................................. 14
valproic acid ........................................................... 19
valsartan-hydrochlorothiazide ........... 34
VALTREX ............................................................. 43
value plus glucose ............................................. 26
value plus lancet standard 21g ........ 114
value plus lancets super thin .............. 114
value plus lancets thin 26g ................... 114
value plus lancing device ........................ 114
valumark lancet super thin 30g ...... 114
valumark lancet ultra thin 28g ....... 114
valumark pen needles ................................ 114
valved holding chamber .......................... 114
VANCOCIN HCL ........................................ 35
vancomycin hcl .................................................... 35
VANDAZOLE ............................................... 143
VANISHPOINT INSULIN
SYRINGE ........................................................... 114
VANOXIDE-HC ............................................ 67
VANTAS .................................................................. 38
VARIBAR HONEY .................................. 74
VARIBAR NECTAR ............................... 75
VARIBAR PUDDING .......................... 75
VARIBAR THIN HONEY ............... 75
VARIBAR THIN LIQUID ............... 75
VASCEPA ............................................................... 30
VASERETIC ....................................................... 34
VASOLEX .............................................................. 67
VASOTEC .............................................................. 34
VCF VAGINAL
CONTRACEPTIVE ............................... 143
VECAMYL ........................................................... 34
VECTICAL ........................................................... 67
VELETRI ................................................................ 48
VELIVET ................................................................. 53
VELPHORO ........................................................ 82
VEMAVITE-PRX 2 ................................ 125
vena-bal dha ........................................................ 125
venatal complete dha ................................. 125
venatal-fa ................................................................ 125
venlafaxine hcl ..................................................... 22
venlafaxine hcl er .............................................. 22
VENOFER ............................................................. 87
VENTAVIS ........................................................... 48
VENTOLIN HFA ......................................... 16
VERAMYST .................................................... 127
verapamil hcl .......................................................... 47
verapamil hcl er .................................................. 47
VERDESO ............................................................. 67
VEREGEN ............................................................ 67
VERELAN ............................................................. 47
VERELAN PM ................................................ 47
VERIPRED 20 .................................................. 54
Index
Index
UNILET LANCET .................................. 113
UNILET SUPERLITE LANCET
............................................................................................. 114
UNIRETIC ............................................................ 34
UNISTIK 1 ........................................................ 114
UNISTIK 2 ........................................................ 114
UNISTIK 2 COMFORT ................... 114
UNISTIK 2 EXTRA .............................. 114
UNISTIK 2 NEONATAL .............. 114
UNISTIK 2 NORMAL ...................... 114
UNISTIK 2 SUPER ................................ 114
UNISTIK 3 ........................................................ 114
UNISTIK 3 COMFORT ................... 114
UNISTIK 3 EXTRA .............................. 114
UNISTIK 3 GENTLE .......................... 114
UNISTIK 3 NEONATAL .............. 114
UNISTIK 3 NORMAL ...................... 114
UNISTIK CZT COMFORT ........ 114
UNISTIK CZT NORMAL ............ 114
UNISTRIP CONTROL ..................... 114
UNISTRIP1 GENERIC ....................... 74
UNITHROID ................................................. 139
UNITHROID DIRECT .................... 139
UNIVASC ............................................................... 34
UNIVERSAL 1 LANCETS THIN
26G ............................................................................... 114
UNIVERSAL 1 LANCETS
ULTRA THIN ............................................... 114
up & up glucose ................................................... 26
ur n-c ........................................................................... 141
URAMAXIN ...................................................... 66
urea ................................................................................... 66
urea hydrating ...................................................... 66
urea in zn undecyl-lactic acid .............. 66
urea nail ....................................................................... 66
urea nail film .......................................................... 67
urea-c40 ....................................................................... 67
URELLE ............................................................... 141
UREX ....................................................................... 141
URIBEL ................................................................. 141
URIMAR-T ...................................................... 141
urin ds ......................................................................... 141
URISTIX .................................................................. 74
URISTIX 4 ............................................................. 74
UROCIT-K 10 ................................................... 83
UROCIT-K 5 ...................................................... 83
UROQID #2 ..................................................... 141
UROXATRAL ................................................. 83
URSO 250 ................................................................ 82
URSO FORTE .................................................. 82
ursodiol ......................................................................... 82
URYL ....................................................................... 141
USTELL ................................................................ 141
UTA ............................................................................ 141
uticap ........................................................................... 141
UTIRA-C ............................................................. 141
UTOPIC .................................................................... 67
UTRONA-C ..................................................... 142
(Updated 07/01/15)
173
............................................................................................. 115
WILATE ................................................................... 85
WINDMILL TRAINER .................. 115
winn dixie medic test ..................................... 75
WINRHO SDF ............................................. 135
WP THYROID ............................................. 139
WYMZYA FE ................................................... 53
XALATAN ........................................................ 132
XALKORI .............................................................. 38
XANAX ..................................................................... 14
XANAX XR ......................................................... 14
XARELTO ............................................................. 17
XARELTO STARTER PACK ..... 17
XARTEMIS XR ............................................. 11
XELJANZ .................................................................. 7
XELODA ................................................................. 38
XENAZINE ...................................................... 137
XEOMIN .............................................................. 128
XERAC AC .......................................................... 67
XERESE ................................................................... 67
XGEVA ...................................................................... 78
XIAFLEX ............................................................... 45
XIFAXAN .............................................................. 35
XIGDUO XR ..................................................... 26
XODOL ..................................................................... 11
XOLAIR ................................................................... 16
XOLEGEL ............................................................. 67
XOPENEX ............................................................. 16
XOPENEX CONCENTRATE ..... 16
XOPENEX HFA ............................................ 16
XPRES CONTROL ................................ 115
XTANDI .................................................................. 38
XULANE ................................................................ 53
X-VIATE .................................................................. 67
XYLOCAINE .................................................... 67
XYNTHA ................................................................ 85
XYNTHA SOLOFUSE ......................... 85
XYREM ................................................................. 137
XYZAL ...................................................................... 29
YASMIN 28 .......................................................... 53
YAZ ................................................................................ 53
YODOXIN ................................................................ 5
zaclir cleansing .................................................... 67
ZADITOR ........................................................... 133
zafirlukast ................................................................. 16
zaleplon ........................................................................ 89
ZAMICET .............................................................. 11
ZANAFLEX .................................................... 127
ZARAH ..................................................................... 53
ZARONTIN ......................................................... 19
ZAROXOLYN ................................................. 76
ZATEAN-CH ................................................. 126
ZATEAN-PN .................................................. 126
ZATEAN-PN DHA ................................ 126
ZATEAN-PN PLUS ............................... 126
ZAVESCA .............................................................. 87
ZAZOLE ............................................................... 143
Index
vp-heme ob ............................................................ 126
vp-heme ob + dha .......................................... 126
vp-heme one ......................................................... 126
vp-pnv-dha ............................................................. 126
VPRIV ......................................................................... 87
V-R MONO INSULIN SYRINGE
............................................................................................. 114
VUSION .................................................................... 67
VYFEMLA ............................................................ 53
VYTONE ................................................................. 67
VYTORIN .............................................................. 30
VYVANSE ................................................................ 5
W&F LANCETS 26G ........................... 115
W&F LANCETS COLORED 21G
............................................................................................. 115
walgreens adv travel lancets .............. 115
walgreens glucose ............................................. 26
WALGREENS LANCETS ............ 115
walgreens lancets micro thin ............. 115
walgreens lancets super thin .............. 115
WALGREENS LANCING
DEVICE ................................................................. 115
WALGREENS THIN LANCETS
............................................................................................. 115
WALGREENS ULTRA THIN
LANCETS ........................................................... 115
WAL-ITIN ............................................................. 29
warfarin sodium .................................................. 17
WATCHHALER ........................................ 115
WAVESENSE PRESTO ....................... 75
WEBCOL ALCOHOL PREP
LARGE ................................................................... 115
WEBCOL ALCOHOL PREP
MEDIUM ............................................................ 115
wegmans unifine pentips plus ........... 115
WELCHOL ........................................................... 30
WELLBUTRIN ............................................... 22
WELLBUTRIN SR .................................... 22
WELLBUTRIN XL ................................... 22
WERA ......................................................................... 53
WESTCORT ........................................................ 67
WESTHROID ................................................ 139
WESTHROID-P .......................................... 139
............................................................................................. 115
............................................................................................. 115
............................................................................................. 115
............................................................................................. 115
............................................................................................. 115
............................................................................................. 115
............................................................................................. 115
Index
Index
virtussin a/c .............................................................. 56
virt-vite ......................................................................... 87
virt-vite plus ......................................................... 125
VISTARIL .............................................................. 14
VISTIDE ................................................................... 44
VISUDYNE ...................................................... 132
VITAFOL ............................................................ 125
VITAFOL ULTRA .................................. 125
VITAFOL-NANO .................................... 125
VITAFOL-OB ................................................ 125
VITAFOL-OB+DHA ........................... 125
VITAFOL-ONE ........................................... 125
VITAFOL-PLUS ........................................ 125
VITAFOL-PN ................................................ 126
VITAL-D RX .................................................. 126
VITALET PRO LANCETS .......... 114
VITALET PRO PLUS LANCETS
............................................................................................. 114
VITAMEDMD ONE
RX/QUATREFOLIC ........................... 126
VITAMEDMD PLUS
RX/QUATREFOLIC ........................... 126
VITAMEDMD REDICHEW RX
............................................................................................. 126
vitamin d (ergocalciferol) ................... 144
vitamin d2 .............................................................. 144
vitamin d3 .............................................................. 144
vitamins acd-fluoride ................................. 126
VITAPEARL ................................................... 126
VITA-PREN ..................................................... 126
VITAZOL ................................................................ 67
VITEKTA ............................................................... 44
VITUZ ......................................................................... 56
VIVA DHA ........................................................ 126
VIVACTIL ............................................................. 22
VIVELLE-DOT ............................................... 80
VIVITROL ............................................................. 27
v-natal dha ............................................................ 126
VOCAL POINT BLOOD
GLUCOSE TEST .......................................... 75
VOCAL POINT CONTROL ....... 114
VOGELXO ............................................................ 12
VOGELXO PUMP ...................................... 12
vol-care rx ............................................................. 126
vol-nate ..................................................................... 126
vol-tab rx ................................................................ 126
VOLTAREN ....................................................... 67
VOLTAREN-XR .............................................. 7
VOLUMEN .......................................................... 75
voriconazole ............................................................ 28
VORTEX VALVED HOLDING
CHAMBER ....................................................... 114
VOSOL HC ........................................................ 134
VOSPIRE ER ..................................................... 16
VOTRIENT .......................................................... 38
vp-ch plus ................................................................ 126
vp-ch-pnv ................................................................. 126
vp-ggr-b6 prenatal ........................................ 126
(Updated 07/01/15)
174
zotane hc ................................................................. 134
ZOVIA 1/35E (28) ......................................... 53
ZOVIA 1/50E (28) ......................................... 53
ZOVIRAX .................................................... 44, 67
ZUBSOLV .............................................................. 11
ZUPLENZ .............................................................. 27
ZYCLARA ............................................................ 67
ZYCLARA PUMP ...................................... 67
ZYFLO ....................................................................... 16
ZYFLO CR ........................................................... 16
ZYLET .................................................................... 133
ZYLOPRIM ......................................................... 83
ZYMAXID ......................................................... 133
ZYPREXA ............................................................. 41
ZYPREXA ZYDIS ...................................... 41
ZYTIGA ................................................................... 38
ZYVOX ...................................................................... 35
Index
Index
Z-COF I ..................................................................... 56
ZEBETA ................................................................... 46
ZEBUTAL ................................................................. 8
ZEGERID ........................................................... 141
ZELAPAR .............................................................. 39
ZELBORAF ......................................................... 38
ZEMAIRA .......................................................... 137
ZEMPLAR ............................................................ 78
ZENATANE ....................................................... 67
ZENCHENT ....................................................... 53
ZENCHENT FE ............................................. 53
ZENCIA .................................................................... 67
ZENPEP .................................................................... 75
ZENZEDI ................................................................... 5
ZEOSA ........................................................................ 53
ZERIT .......................................................................... 44
ZESTORETIC ................................................... 34
ZESTRIL ................................................................. 34
ZETIA .......................................................................... 30
ZETONNA ......................................................... 128
ZIAC .............................................................................. 34
ZIAGEN ................................................................... 44
zidovudine .................................................................. 44
zingiber ..................................................................... 126
ZIOPTAN ............................................................ 133
ziprasidone hcl ..................................................... 41
ZIPSOR ......................................................................... 7
ZIRGAN ............................................................... 133
ZITHRANOL .................................................... 67
ZITHRANOL-RR ....................................... 67
ZITHROMAX .................................................. 90
ZITHROMAX TRI-PAK ................... 90
ZITHROMAX Z-PAK ........................... 90
ZMAX ......................................................................... 90
ZOCOR ...................................................................... 30
ZOFRAN ................................................................. 27
ZOFRAN ODT ................................................ 27
ZOHYDRO ER ............................................... 11
ZOLADEX ............................................................ 38
zoledronic acid ..................................................... 78
ZOLINZA ............................................................... 38
zolmitriptan ......................................................... 116
ZOLOFT ................................................................... 22
zolpidem tartrate ............................................... 89
zolpidem tartrate er ....................................... 89
ZOLPIMIST ......................................................... 89
ZOLVIT ..................................................................... 11
ZOMACTON ..................................................... 79
ZOMETA ................................................................ 79
ZOMIG ................................................................... 116
ZOMIG ZMT .................................................. 116
ZONALON ........................................................... 67
ZONATUSS ......................................................... 56
ZONEGRAN ...................................................... 19
zonisamide ................................................................ 19
ZORBTIVE ........................................................... 79
ZORTRESS .......................................................... 45
ZORVOLEX ........................................................... 7
(Updated 07/01/15)
175

Aetna`s Pharmacy Tier Listing

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