REVISED March 5 TIER Formulary doc

Transcription

D‌rug Name
Drug
Tier
Requirements/‌Limits
Analgesics
Analgesics, Miscellaneous
acetaminophen with codeine
(Vopac)
acetaminophen/‌phenyltolx cit
(Staflex)
butalb/‌acetaminophen/‌caffeine (Esgic)
butalbit/‌acetamin/‌caff/‌codeine
(Fioricet with
Codeine)
butalbital/‌acetaminophen
(Tencon)
butorphanol tartrate
(Butorphanol Tartrate)
codeine phos/‌acetaminophen
(Codeine
Phos/‌acetaminophen)
codeine sulfate
(Codeine Sulfate)
CODEINE SULFATE
codeine/‌butalbital/‌asa/‌caffein
(Fiorinal w/‌Codeine
#3)
dhcodeine bt/‌acetaminophn/‌caff (Panlor SS)
fentanyl citrate
(Actiq)
1
1
1
1
1
1
1
1
1
1
1
1
fentanyl
(Duragesic)
hydrocodone bit/‌acetaminophen (Norco)
1
1
hydrocodone/‌ibuprofen
hydromorphone hcl
ibuprofen/‌oxycodone hcl
isometheptene/‌acetaminoph/‌caff
(Ibudone)
(Dilaudid)
(Combunox)
(Isometheptene/‌aceta
minoph/‌caff)
(Levo-dromoran)
(Demerol)
(Meperidine HCl/‌PF)
(Methadose)
1
1
1
1
(Morphine Sulfate In
0.9 % NaCl)
(Kadian) (Eff 3/1/14
Tier Changed from 1
to 2)
1
levorphanol tartrate
meperidine hcl
meperidine hcl/‌pf
methadone hcl
morphine sulfate in 0.9 % nacl
morphine sulfate
HealthSpan Formulary – RX_2014 Formulary_5T
Formulary ID: 82112.000, Version:
spray
capsule: 30-50-325
tablet
PA, QL: 120 in 30
days
various dosage
and/‌or strengths are
available
tablet: 7.5-200mg
supp.rect, tablet, vial
1
1
1
1
2
oral conc, solution,
tablet, tablet sol
QL: 60 in 30 days
cap er pel
90mg, 120mg,
45mg, 75mg
Effective: January 01, 2014
Page 1 of 126
D‌rug Name
Drug
Tier
morphine sulfate
(MS Contin)
1
morphine sulfate/‌d5w
(Morphine
Sulfate/‌D5W)
(Morphine Sulfate/‌PF)
1
morphine sulfate/‌pf
(Dazidox)
(Alcet)
(Endodan)
(Opana)
1
1
1
1
1
oxymorphone hcl
oxymorphone hcl
(Oxymorphone HCl)
(Oxymorphone HCl)
1
1
pentazocine hcl/‌acetaminophen
pentazocine hcl/‌naloxone hcl
sal-amide/‌acetaminophn/‌p-tlox
tramadol hcl
tramadol hcl/‌acetaminophen
AVINZA
dihydrocodeine/‌aspirin/‌caffein
DILAUDID
hydrocodone/‌ibuprofen
(Talacen)
(Talwin NX)
(Asp)
(Ultram)
(Ultracet)
1
1
1
1
1
2
2
2
2
hydromorphone hcl
METHADOSE
opium/‌belladonna alkaloids
(Dilaudid)
tramadol hcl
ABSTRAL
(Ibudone)
(B & O Supprettes
No.15-a)
(Tramadol HCl)
cartridge, disp syrin,
pen injctr, solution,
supp.rect, tablet,
tablet er, vial:
10mg/‌ml
1
OXECTA
oxycodone hcl
oxycodone hcl/‌acetaminophen
oxycodone hcl/‌aspirin
oxymorphone hcl
(Synalgos-dc)
pca vial:
150mg/‌30ml
QL: 120 in 30 days tab er 12h: 15mg;
tablet
tab er 12h: 7.5mg
QL: 60 in 30 days tab er 12h: 5mg,
10mg, 20mg, 30mg,
40mg
tab er 24h, tablet
QL: 30 in 30 days
liquid
tablet: 2.5-200mg,
5mg-200mg, 10mg200mg
liquid
2
2
2
2
3
cpmp 25-75
PA, QL: 120 in 30
days
Page 2 of 126
D‌rug Name
Drug
Tier
ACTIQ
3
ANABAR
BUTORPHANOL TARTRATE
BUTRANS
CAPITAL W-CODEINE
CODEINE PHOSPHATE
CONZIP
3
3
3
3
3
3
DEMEROL
3
DEMEROL
dhcodeine bt/‌acetaminophn/‌caff (Dhcodeine
Bt/‌acetaminophn/‌caff)
DILAUDID
DOLGIC PLUS
DOLOGESIC
DOLOPHINE HCL
DURAGESIC
DURAXIN
EMBEDA
ESGIC
ESGIC-PLUS
EXALGO
FENTORA
3
3
FIORICET with CODEINE
FIORICET
FIORINAL with CODEINE #3
HYCET
hydrocodone bit/‌acetaminophen (Norco)
3
3
3
3
3
HYDROMORPHONE HCL
IBUDONE
KADIAN
LAZANDA
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
PA, QL: 120 in 30
days
QL: 4 in 30 days
ST, QL: 30 in 30
days
ampul, disp syrin:
25mg/‌ml, 50mg/‌ml
tablet
capsule
tablet
QL: 30 in 30 days
PA, QL: 112 in 30
days
tablet: 5mg-300mg,
7.5-300mg, 10mg300mg
QL: 60 in 30 days
PA, QL: 15 in 30
days
Page 3 of 126
D‌rug Name
Drug
Tier
LEVORPHANOL TARTRATE
LORCET 10-650
LORCET PLUS
LORTAB
MAGNACET
MAXIDONE
MEPERIDINE HCL
METHADONE HCL
MIGRALAM
MIGRATEN
MORPHINE SULFATE
MS CONTIN
MSIR
NORCO
NUCYNTA ER
NUCYNTA
NUMORPHAN
ONSOLIS
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
OPANA ER
OPANA
ORBIVAN CF
ORBIVAN
OXYCODONE
HYDROCHLORIDE
OXYCONTIN
OXYCONTIN
3
3
3
3
3
PERCOCET
PERCODAN
PERCOLONE
PHRENILIN FORTE
PRIMLEV
ROXICODONE
RYBIX ODT
3
3
3
3
3
3
3
SUBSYS
3
3
3
QL: 60 in 30 days
QL: 180 in 30 days
PA NSO, QL: 120
in 30 days
QL: 60 in 30 days
QL: 120 in 30 days tablet
QL: 120 in 30 days tab er 12h: 80mg
QL: 60 in 30 days tab er 12h: 10mg,
15mg, 20mg, 30mg,
40mg, 60mg
ST, QL: 360 in 30
days
PA NSO
Page 4 of 126
D‌rug Name
Drug
Tier
SYNALGOS-DC
TENCON
TRAMADOL HCL
TYLENOL-CODEINE NO.3
TYLENOL-CODEINE NO.4
TYLOX
ULTRACET
ULTRAM ER
ULTRAM
VICOPROFEN
XODOL 10-300
XODOL 5-300
XODOL 7.5-300
XOLOX
ZAMICET
ZEBUTAL
ZGESIC
ZYDONE
DEMEROL
nalbuphine hcl
(Nalbuphine HCl)
SUBLIMAZE
TALWIN
Nonsteroidal Anti-inflammatory Agents
aspirin
(Aspirin)
butalbital/‌aspirin/‌caffeine (Fiorinal)
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
4
4
4
choline sal/‌mag salicylate
diclofenac potassium
diclofenac sodium
etodolac
fenoprofen calcium
flurbiprofen
ibuprofen
(Choline Sal/‌mag Salicylate)
(Cataflam)
(Voltaren)
(Etodolac)
(Fenoprofen Calcium)
(Ansaid)
(Motrin)
1
1
1
1
1
1
1
indomethacin
ketoprofen
ketorolac tromethamine
meclofenamate sodium
(Indomethacin)
(Ketoprofen)
(Toradol)
(Meclofenamate Sodium)
1
1
1
1
1
1
QL: 360 in 30 days
PA
PA
PA
PA
disp syrin: 75mg/‌ml
vial
supp.rect, tablet dr: 650mg
capsule: 50-325-40; tablet:
50-325-40
oral susp, tablet: 400mg,
600mg, 800mg
tablet
Page 5 of 126
D‌rug Name
mefenamic acid
meloxicam
nabumetone
naproxen sodium
naproxen
oxaprozin
piroxicam
salsalate
sulindac
tolmetin sodium
diclofenac
sodium/‌misoprostol
diflunisal
ANAPROX DS
ANAPROX
ARTHROTEC 50
ARTHROTEC 75
CAMBIA
Drug
Tier
(Ponstel)
(Mobic)
(Relafen)
(Anaprox)
(Naprosyn)
(Oxaprozin)
(Feldene)
(Salflex)
(Clinoril)
(Tolmetin Sodium)
(Arthrotec 50)
1
1
1
1
1
1
1
1
1
1
2
(Diflunisal)
2
3
3
3
3
3
CATAFLAM
CELEBREX
3
3
CELEBREX
3
CELEBREX
3
CHOLINE
MAGNESIUM
TRISALICYLAT
CLINORIL
DAYPRO
DICLOFENAC
SODIUM
DIFLUNISAL
DUEXIS
EC-NAPROSYN
FELDENE
FIORINAL
3
ST, QL: 9 in
30 days
PA, QL: 30
in 30 days
ST, QL: 30
in 30 days
ST, QL: 60
in 30 days
capsule: 400mg
capsule: 200mg
capsule: 50mg, 100mg
3
3
3
3
3
3
3
3
ST
Page 6 of 126
D‌rug Name
FLECTOR
FLURBIPROFEN
IBUPROFEN
INDOCIN
INDOMETHACIN
KETOPROFEN
KETOROLAC
TROMETHAMINE
LEVACET
MECLOFENAMATE
SODIUM
MELOXICAM
methyl salicylate
MOBIC
NALFON
NAPRELAN
NAPROSYN
NAPROXEN
PENNSAID
PIROXICAM
PONSTEL
SALSALATE
SOLARAZE
SPRIX
Drug
Tier
3
3
3
3
3
3
3
3
3
(Methyl Salicylate)
3
3
3
3
3
3
3
3
3
3
3
3
3
SULINDAC
VIMOVO
VOLTAREN
VOLTAREN-XR
ZIPSOR
3
3
3
3
3
butalbital/‌aspirin/‌caffeine (Fiorinal)
5
QL: 5 in 30
days
ST
ST, QL: 120
in 30 days
capsule: 50-325-40; tablet:
50-325-40
Page 7 of 126
D‌rug Name
Drug
Tier
Anesthetics
Local Anesthetics
antipyrine/‌benzocaine/‌gly (Otra Nr)
cerin
lidocaine hcl
(Xylocaine)
lidocaine
lidocaine/‌prilocaine
aa/‌antipyrn/‌bcaine/‌polico
#1/‌al
lidocaine hcl
EMLA
LIDOCAINE HCL
LIDOCAINE
LIDODERM
PLIAGLIS
SYNERA
1
1
(Lidocaine)
(EMLA)
(Auralgan)
1
1
2
(Xylocaine)
2
3
3
3
3
3
4
jel (ml), solution:
20mg/‌ml, 40mg/‌ml
solution: 4%
powder: 100%
PA
Anti-addiction/‌substance Abuse Treatment Agents
Anti-addiction/‌substance Abuse Treatment Agents
buprenorphine hcl
(Subutex)
1
disulfiram
(Antabuse)
1
naltrexone hcl
(Revia)
1
buprenorphine
(Suboxone)
2
hcl/‌naloxone hcl
ANTABUSE
3
CAMPRAL
3
CHANTIX
3
CHANTIX
3
CHANTIX
3
REVIA
SUBOXONE
ZYBAN
naloxone hcl
3
3
3
4
(Naloxone HCl)
VIVITROL
PA
QL: 106 in
365 days
QL: 336 in
365 days
QL: 672 in
365 days
tab ds pk
PA
disp syrin: 0.4mg/‌ml; vial:
0.4mg/‌ml
tablet: 1mg
tablet: 0.5mg
4
Page 8 of 126
D‌rug Name
Drug
Tier
Antianxiety Agents
Benzodiazepines
ALPRAZOLAM
INTENSOL
alprazolam
chlordiazepoxide hcl
clonazepam
(Xanax)
(Librium)
(Klonopin)
1
1
1
clorazepate dipotassium
diazepam
(Tranxene T-tab)
(Valium)
1
1
estazolam
flurazepam hcl
lorazepam
midazolam hcl
oxazepam
temazepam
triazolam
ONFI
quazepam
ALPRAZOLAM
ATIVAN
CLONAZEPAM
DIASTAT ACUDIAL
DIASTAT
DIAZEPAM
DORAL
HALCION
KLONOPIN
LORAZEPAM
MIDAZOLAM
NIRAVAM
RESTORIL
TRANXENE T-TAB
VALIUM
XANAX XR
XANAX
(Prosom)
(Dalmane)
(Ativan)
(Midazolam HCl)
(Oxazepam)
(Restoril)
(Halcion)
1
1
1
1
1
1
1
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
1
(Quazepam)
tab rapdis, tablet: 0.5mg,
1mg, 2mg
kit, oral conc, solution,
tablet
oral conc, tablet
syrup
tablet
tablet
Antibacterials
Page 9 of 126
D‌rug Name
Aminoglycosides
neomycin sulfate
(Neomycin Sulfate)
GENTAMICIN
SULFATE
NEOMYCIN SULFATE
TOBRAMYCIN
SULFATE
TOBRAMYCIN
amikacin sulfate
(Amikacin Sulfate)
kanamycin sulfate
(Kanamycin Sulfate)
streptomycin sulfate
(Streptomycin Sulfate)
TOBI PODHALER
TOBI
tobramycin sulfate
(Nebcin)
Antibacterials, Miscellaneous
clindamycin hcl
(Cleocin HCl)
clindamycin palmitate hcl (Cleocin Palmitate)
methen/‌m-blue/‌sal/‌na
(Uta)
phos/‌hyos
methenamine mandelate (Mandelamine)
mth/‌me blue/‌sod
(Mth/‌me Blue/‌sod
phos/‌phen/‌hyos
Phos/‌phen/‌hyos)
nitrofurantoin
(Macrodantin)
macrocrystal
nitrofurantoin
(Furadantin)
PHOSPHASAL
trimethoprim
(Trimethoprim)
URYL
bacitracin
(Bacitracin)
methen/‌sod phos/‌meth
(Uryl)
blue/‌hyos
UROQID-ACID NO.2
vancomycin hcl
(Vancocin HCl)
CLEOCIN HCL
CLEOCIN PALMITATE
CLINDAMYCIN HCL
FURADANTIN
HIPREX
Drug
Tier
1
3
3
3
3
4
4
4
4
4
4
1
1
1
PA
PA
PA
vial: 100mg/‌2ml
vial: 1g/‌3ml
PA
vial
capsule
1
1
1
1
1
1
1
2
2
2
2
3
3
3
3
3
vial: 50000unit
capsule
Page 10 of 126
D‌rug Name
MACROBID
MACRODANTIN
methen/‌m-blue/‌sal/‌na
phos/‌hyos
MONUROL
NITROFURANTOIN
NITROFURANTOIN
PRIMSOL
TRIMETHOPRIM
URELLE
URIBEL
URIN D.S.
UTA
VANCOCIN HCL
VANCOMYCIN HCL
XIFAXAN
XIFAXAN
ZYVOX
chloramphenicol sod succ
CUBICIN
LINCOCIN
polymyxin b sulfate
VIBATIV
Cephalosporins
cefaclor
cefadroxil hydrate
cefdinir
cefditoren pivoxil
cefpodoxime proxetil
cefprozil
cefuroxime axetil
cephalexin
CEFTIN
SPECTRACEF
SUPRAX
CEDAX
(Methen/‌m-blue/‌sal/‌na
Phos/‌hyos)
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
(Chloramphenicol Sod Succ)
(Polymyxin B Sulfate)
(Ceclor)
(Cefadroxil Hydrate)
(Omnicef)
(Spectracef)
(Vantin)
(Cefzil)
(Ceftin)
(Keflex)
3
4
4
4
4
4
1
1
1
1
1
1
1
1
2
2
2
3
tablet
powder: 100%
powder: n/‌a
powder
PA
tablet: 550mg
QL: 63 in 21 tablet: 200mg
days
PA
susp recon, tablet
PA
PA
PA
PA
PA
susp recon
Page 11 of 126
D‌rug Name
CEFTAZIDIMESODIUM CARBONATE
CEFTIN
KEFLEX
cefazolin sodium
CEFEPIME
cefotetan disodium
cefoxitin
sodium/‌dextrose,iso
CEFTAZIDIME
ceftriaxone sodium
CLAFORAN
TEFLARO
TEFLARO
Macrolides
azithromycin
clarithromycin
ery e-succ/‌sulfisoxazole
erythromycin base
erythromycin
ethylsuccinate
erythromycin stearate
E.E.S. 200
ERYPED 200
ERYPED 400
erythromycin base
ZMAX
AZITHROMYCIN
BIAXIN XL
BIAXIN
DIFICID
ERY-TAB
ERYTHROMYCIN
ETHYLSUCCINATE
ERYTHROMYCIN
KETEK
PCE
Drug
Tier
3
(Ancef)
(Cefotetan Disodium)
(Cefoxitin Sodium/‌dextrose,
Iso)
(Rocephin)
3
3
4
4
4
4
4
4
4
4
4
(Zithromax)
(Biaxin)
(Pediazole)
(Erythromycin Base)
1
1
1
1
(Erythromycin
Ethylsuccinate)
(Erythromycin Stearate)
1
(Erythromycin Base)
1
2
2
2
2
2
3
3
3
3
3
3
tablet
PA
PA
PA
PA
vial: 10g
PA
PA
PA
piggyback: 1g/‌50ml
vial: 10g
vial: 10g
vial: 600mg
vial: 400mg
PA
vial: 10g
packet, susp recon, tablet
capsule dr, tablet, tablet dr:
250mg
tablet dr: 500mg
ST
3
3
3
Page 12 of 126
D‌rug Name
Drug
Tier
ZITHROMAX TRI-PAK
ZITHROMAX
Miscellaneous B-lactam Antibiotics
CAYSTON
DORIBAX
INVANZ
MERREM
PRIMAXIN
Penicillins
amoxicillin
(Amoxil)
amoxicillin/‌potassium
(Augmentin)
clav
AMOXIL
ampicillin trihydrate
(Ampicillin Trihydrate)
dicloxacillin sodium
(Dicloxacillin Sodium)
penicillin v potassium
(Veetids 500)
AUGMENTIN
AMOXICILLIN
TRIHYDRATE
AUGMENTIN ES-600
AUGMENTIN XR
AUGMENTIN
3
3
MOXATAG
ampicillin
sodium/‌sulbactam na
nafcillin sodium
oxacillin sodium
pen g pot/‌dextrose-water
TIMENTIN
ZOSYN
Quinolones
ciprofloxacin hcl
ciprofloxacin/‌ciprofloxa
hcl
levofloxacin
ofloxacin
AVELOX ABC PACK
3
4
PA
vial: 3g
4
4
4
4
4
PA
PA
PA
PA
PA
vial: 10g
vial: 10g
froz.piggy: 1mm/‌50ml
(Unasyn)
(Unipen)
(Oxacillin Sodium)
(Pen G Pot/‌dextrose-water)
4
4
4
4
4
vial: 500mg
vial port
vial: 500mg
1
1
1
1
1
1
2
3
susp recon: 125-31.25/‌
3
3
3
(Cipro)
(Cipro XR)
1
1
(Levaquin)
(Floxin)
1
1
2
PA
PA
PA
PA
PA
susp recon: 250-62.5/‌5,
400-57mg/‌5; tablet
froz.piggy: 4.5g/‌100ml
solution, tablet
Page 13 of 126
D‌rug Name
moxifloxacin hcl
CIPRO
CIPRO XR
CIPRO
CIPROFLOXACIN HCL
FACTIVE
LEVAQUIN
LEVOFLOXACIN
HEMIHYDRATE
NOROXIN
Sulfonamides
sulfadiazine
sulfamethoxazole/‌trimeth
oprim
sulfasalazine
AZULFIDINE
BACTRIM DS
BACTRIM
SULFACETAMIDE
SOD MONOHYDRATE
SULFACETAMIDE
SULFADIAZINE
SODIUM
SULFADIAZINE
SULFAMETHOXAZOL
E
SULFASALAZINE
SULFISOXAZOLE
Tetracyclines
ALA-TET
ALODOX
demeclocycline hcl
doxycycline hyclate
AVELOX
Drug
Tier
2
2
3
3
3
3
3
3
400mg
sus mc rec
tablet
solution, tablet
3
(Sulfadiazine)
(Septra)
1
1
(Azulfidine)
1
3
3
3
3
oral susp, tablet
3
3
3
3
3
3
(Declomycin)
(Morgidox)
doxycycline monohydrate (Adoxa)
minocycline hcl
(Dynacin)
minocycline hcl
(Solodyn)
1
1
1
1
1
1
1
PA
capsule: 50mg, 100mg;
capsule dr, tablet: 20mg;
tablet dr
capsule: 150mg; tablet
capsule, tablet
tab er 24h
Page 14 of 126
D‌rug Name
tetracycline hcl
VIBRAMYCIN
VIBRAMYCIN
ADOXA CK
ADOXA PAK
ADOXA TT
ADOXA
AVIDOXY
DORYX
DOXYCYCLINE
HYCLATE
DYNACIN
MINOCIN
MINOCYCLINE HCL
MONODOX
MORGIDOX
ORACEA
SOLODYN
TETRACYCLINE HCL
TETRACYCLINE
VIBRAMYCIN
TYGACIL
(Ala-tet)
Drug
Tier
1
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
susp recon
syrup
PA
PA
PA
PA
PA
capsule
PA
PA
PA
capsule
PA
Anticancer Agents
Anticancer Agents
anastrozole
(Arimidex)
bicalutamide
(Casodex)
cyclophosphamide
(Cyclophosphamide)
etoposide
(Etoposide)
exemestane
(Aromasin)
flutamide
(Flutamide)
hydroxyurea
(Hydrea)
letrozole
(Femara)
megestrol acetate
(Megace)
mercaptopurine
(Purinethol)
methotrexate sodium
(Methotrexate Sodium)
methotrexate sodium/‌pf
(Methotrexate Sodium/‌PF)
tamoxifen citrate
(Nolvadex)
tretinoin
(Tretinoin)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ST
tablet
capsule
Page 15 of 126
D‌rug Name
ALKERAN
CEENU
DROXIA
EMCYT
FARESTON
LEUKERAN
LYSODREN
MYLERAN
TREXALL
ANASTROZOLE
ARIMIDEX
AROMASIN
CASODEX
CYCLOPHOSPHAMIDE
ETOPOSIDE
FEMARA
FLUOROURACIL
HEXALEN
HYCAMTIN
HYDREA
HYDROXYUREA
MATULANE
MEGACE ES
MEGACE
MEGESTROL
ACETATE
MERCAPTOPURINE
NILANDRON
PURINETHOL
RHEUMATREX
TABLOID
TAMOXIFEN CITRATE
TARGRETIN
ZOLINZA
AFINITOR DISPERZ
AFINITOR
ARZERRA
BOSULIF
Drug
Tier
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
4
4
4
tablet
ST
ST
ST
ST
capsule
PA
PA
PA
PA
Page 16 of 126
D‌rug Name
BUSULFEX
CAPRELSA
COMETRIQ
ELSPAR
ERIVEDGE
ETOPOPHOS
FIRMAGON
fludarabine phosphate
GLEEVEC
ICLUSIG
INLYTA
JAKAFI
leuprolide acetate
MEKINIST
melphalan hcl
mitoxantrone hcl
NEXAVAR
OFORTA
POMALYST
REVLIMID
RITUXAN
SPRYCEL
STIVARGA
SUTENT
TAFINLAR
TARCEVA
TASIGNA
TEMODAR
topotecan hcl
TORISEL
TRELSTAR
TYKERB
VOTRIENT
XALKORI
capecitabine
(Fludara)
(Lupron)
(Alkeran)
(Novantrone)
(Hycamtin)
XELODA (Eff 3/1/14 Tier
Change from 4 to 2)
XTANDI
YERVOY
Drug
Tier
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
2
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
4
4
PA
PA
PA
PA
PA
PA
PA
PA
PA
vial: 80mg
disp syrin: 11.25/‌2ml
150mg, 500mg
Page 17 of 126
D‌rug Name
ZANOSAR
ZELBORAF
ZYTIGA
Drug
Tier
4
4
4
PA
PA
PA
Anticholinergic Agents
Antimuscarinics/‌Antispasmodics
chlordiazepoxide/‌clidiniu (Librax)
m br
CYSTOSPAZ-M
hyoscyamine sulfate
(Hyoscyamine Sulfate)
LEVBID
phenobarb/‌hyoscy/‌atropi (Phenobarb/‌hyoscy/‌atropine/‌
ne/‌scop
scop)
propantheline bromide
(Propantheline Bromide)
BELLADONNA
DICYCLOMINE HCL
DONNATAL
GLYCOPYRROLATE
HYOSCYAMINE
SULFATE
LIBRAX
METHSCOPOLAMINE
BROMIDE
PAMINE FQ
PROPANTHELINE
BROMIDE
SYMAX DUOTAB
SYMAX-SR
atropine sulfate
(Atropine Sulfate)
1
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
3
4
PA
disp syrin: 0.05mg/‌ml
Anticonvulsants
Anticonvulsants
carbamazepine
divalproex sodium
ethosuximide
felbamate
gabapentin
lamotrigine
(Tegretol)
(Depakote ER)
(Zarontin)
(Felbatol)
(Neurontin)
(Lamictal)
1
1
1
1
1
1
levetiracetam
(Keppra)
1
tab ds pk, tablet, tb chw
dsp
solution, tab er 24h, tablet
Page 18 of 126
D‌rug Name
oxcarbazepine
phenobarbital
phenytoin sodium
extended
phenytoin
primidone
topiramate
valproate sodium
valproic acid
zonisamide
BANZEL
CELONTIN
DEPAKOTE ER
DEPAKOTE
DILANTIN-125
DILANTIN
DILANTIN
GABITRIL
lamotrigine
LYRICA
PEGANONE
PHENYTEK
TEGRETOL XR
tiagabine hcl
VIMPAT
CARBAMAZEPINE
CARBATROL
DEPAKENE
DEPAKENE
DEPAKOTE ER
DEPAKOTE SPRINKLE
EQUETRO
ETHOSUXIMIDE
FELBATOL
GABAPENTIN
GRALISE
HORIZANT
KEPPRA XR
Drug
Tier
(Trileptal)
(Phenobarbital)
(Dilantin)
1
1
1
(Dilantin)
(Mysoline)
(Topamax)
(Depakene)
(Depakene)
(Zonegran)
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
(Lamictal XR)
(Gabitril)
solution
tab er 24h: 250mg
capsule
tab chew
tab er 24
capsule
solution
tab er 24h: 500mg
ST
ST
Page 19 of 126
D‌rug Name
KEPPRA
LAMICTAL (BLUE)
LAMICTAL (GREEN)
LAMICTAL (ORANGE)
LAMICTAL ODT
(BLUE)
LAMICTAL ODT
(GREEN)
LAMICTAL ODT
(ORANGE)
LAMICTAL ODT
LAMICTAL XR (BLUE)
LAMICTAL XR
(GREEN)
LAMICTAL XR
(ORANGE)
LAMICTAL XR
LAMICTAL
MYSOLINE
NEURONTIN
OXTELLAR XR
PHENYTOIN SODIUM
POTIGA
SABRIL
STAVZOR
TEGRETOL
TOPAMAX
TOPIRAMATE
TRILEPTAL
VALPROATE SODIUM
VALPROIC ACID
ZARONTIN
ZONEGRAN
fosphenytoin sodium
(Cerebyx)
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
ST
PA
PA
Antidementia Agents
Antidementia Agents
donepezil hcl
(Aricept)
galantamine hbr
(Razadyne ER)
1
1
Page 20 of 126
D‌rug Name
rivastigmine tartrate
NAMENDA
ARICEPT ODT
ARICEPT
ARICEPT
EXELON
EXELON
NAMENDA XR
NAMENDA XR
RAZADYNE ER
RAZADYNE
(Exelon)
Drug
Tier
1
2
3
3
3
3
3
3
3
3
3
ST
ST
tablet: 5mg, 10mg
tablet: 23mg
capsule, solution
patch td24
cap spr 24
cap24 dspk
Antidepressants
Antidepressants
amitrip
hcl/‌chlordiazepoxide
amitriptyline hcl
amoxapine
bupropion hcl
citalopram hydrobromide
clomipramine hcl
desipramine hcl
doxepin hcl
escitalopram oxalate
escitalopram oxalate
(Limbitrol)
1
(Amitriptyline HCl)
(Amoxapine)
(Wellbutrin)
(Celexa)
(Anafranil)
(Norpramin)
(Doxepin HCl)
(Lexapro)
(Lexapro)
1
1
1
1
1
1
1
1
1
fluoxetine hcl
fluvoxamine maleate
imipramine hcl
imipramine pamoate
maprotiline hcl
mirtazapine
nefazodone hcl
nortriptyline hcl
olanzapine/‌fluoxetine hcl
paroxetine hcl
perphenazine/‌amitriptylin
e hcl
phenelzine sulfate
(Prozac)
(Fluvoxamine Maleate)
(Tofranil)
(Tofranil-PM)
(Maprotiline HCl)
(Remeron)
(Nefazodone HCl)
(Pamelor)
(Symbyax)
(Paxil)
(Perphenazine/‌amitriptyline
HCl)
(Nardil)
1
1
1
1
1
1
1
1
1
1
1
solution
QL: 30 in 30 tablet
days
tablet
1
Page 21 of 126
D‌rug Name
Drug
Tier
protriptyline hcl
sertraline hcl
tranylcypromine sulfate
trazodone hcl
trimipramine maleate
VENLAFAXINE HCL
ER
VENLAFAXINE HCL
ER
venlafaxine hcl
(Vivactil)
(Zoloft)
(Parnate)
(Trazodone HCl)
(Surmontil)
(Effexor XR)
1
venlafaxine hcl
(Effexor XR)
1
venlafaxine hcl
fluvoxamine maleate
AMITRIPTYLINE HCL
ANAFRANIL
APLENZIN
(Effexor)
(Luvox CR)
1
2
3
3
3
BUPROPION HCL
CELEXA
CLOMIPRAMINE HCL
duloxetine hcl
duloxetine hcl
1
1
1
1
1
1
1
CYMBALTA (Eff 3/1/14
Tier Change from 3 to 2)
CYMBALTA (Eff 3/1/4 Tier
Change from 3 to 2)
3
3
3
2
2
DESVENLAFAXINE ER
DOXEPIN HCL
EFFEXOR XR
3
3
3
EFFEXOR XR
3
EMSAM
FLUOXETINE HCL
FORFIVO XL
IMIPRAMINE HCL
LEXAPRO
3
3
3
3
3
QL: 30 in 30
days
QL: 60 in 30
days
QL: 30 in 30
days
QL: 60 in 30
days
tab er 24: 37.5mg, 75mg,
225mg
tab er 24: 150mg
cap er 24h: 37.5mg, 75mg
cap er 24h: 150mg
tablet
cap er 24h
QL: 30 in 30
days
QL: 30 in 30 capsule dr: 60mg
days
QL: 60 in 30 capsule dr: 20mg, 30mg
days
QL: 30 in 30 cap er 24h: 37.5mg, 75mg
days
QL: 60 in 30 cap er 24h: 150mg
days
ST
QL: 30 in 30
days
Page 22 of 126
D‌rug Name
Drug
Tier
LUVOX CR
MARPLAN
NARDIL
NORPRAMIN
NORTRIPTYLINE HCL
OLEPTRO ER
PAMELOR
PARNATE
PAXIL CR
PAXIL
PEXEVA
PHENELZINE
SULFATE
PRISTIQ ER
3
3
3
3
3
3
3
3
3
3
3
3
PROZAC WEEKLY
PROZAC
REMERON
SARAFEM
SERTRALINE HCL
SILENOR
SURMONTIL
SYMBYAX
TOFRANIL
TOFRANIL-PM
TRAZODONE HCL
TRIMIPRAMINE
MALEATE
VIIBRYD
VIVACTIL
WELLBUTRIN SR
WELLBUTRIN XL
WELLBUTRIN
ZOLOFT
3
3
3
3
3
3
3
3
3
3
3
3
3
ST, QL: 30
in 30 days
3
3
3
3
3
3
Antidiabetic Agents
Antidiabetic Agents, Miscellaneous
acarbose
(Precose)
metformin hcl
(Glucophage)
1
1
Page 23 of 126
D‌rug Name
nateglinide
BYDUREON
BYETTA
JANUMET XR
JANUMET
JANUVIA
KOMBIGLYZE XR
ONGLYZA
PRANDIN
CYCLOSET
FORTAMET
GLUCOPHAGE XR
GLUCOPHAGE
GLUMETZA
GLYSET
INVOKANA
JENTADUETO
JUVISYNC
KAZANO
METFORMIN
HYDROCHLORIDE
NESINA
OSENI
PRANDIMET
PRECOSE
RIOMET
STARLIX
SYMLIN
SYMLINPEN 120
SYMLINPEN 60
TRADJENTA
VICTOZA 3-PAK
KORLYM
Insulins
APIDRA SOLOSTAR
APIDRA
HUMALOG MIX 50-50
HUMALOG MIX 75-25
(Starlix)
Drug
Tier
1
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
ST
ST
ST
PA
PA
PA
ST
PA NSO
2
2
2
2
Page 24 of 126
D‌rug Name
HUMALOG
HUMULIN 70-30
HUMULIN N
HUMULIN R
LANTUS SOLOSTAR
LANTUS
LEVEMIR FLEXPEN
LEVEMIR
NOVOLIN 70-30
INNOLET
NOVOLIN 70-30
NOVOLIN N INNOLET
NOVOLIN N
NOVOLIN R
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30
FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG
Sulfonylureas
chlorpropamide
glimepiride
glipizide
glipizide/‌metformin hcl
glyburide
glyburide,micronized
glyburide/‌metformin hcl
tolazamide
tolbutamide
GLYNASE
AMARYL
DIABETA
GLIPIZIDE
GLUCOTROL XL
GLUCOTROL
GLUCOVANCE
GLYBURIDE
GLYNASE
Drug
Tier
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
(Chlorpropamide)
(Amaryl)
(Glucotrol)
(Metaglip)
(Micronase)
(Glynase)
(Glucovance)
(Tolazamide)
(Tolbutamide)
1
1
1
1
1
1
1
1
1
2
3
3
3
3
3
3
3
3
tablet: 1.5mg
tablet: 3mg, 6mg
Page 25 of 126
D‌rug Name
Thiazolidinediones
pioglitazone hcl
(Actos)
pioglitazone
(Actoplus Met)
hcl/‌metformin hcl
DUETACT
pioglitazone
(Duetact)
hcl/‌glimepiride
ACTOPLUS MET XR
ACTOPLUS MET
ACTOS
AVANDAMET
AVANDARYL
AVANDIA
Drug
Tier
1
1
2
2
3
3
3
3
3
3
ST
ST
ST
Antifungals
Antifungals
ciclopirox olamine
ciclopirox
clotrimazole
clotrimazole/‌betamethaso
ne dip
econazole nitrate
fluconazole
flucytosine
griseofulvin,microsize
itraconazole
ketoconazole
miconazole nitrate
nystatin
nystatin/‌triamcin
sodium thiosulfate/‌sal
acid
terbinafine hcl
voriconazole
griseofulvin
ultramicrosize
griseofulvin,microsize
GRIS-PEG
NOXAFIL
(Loprox)
(Penlac)
(Mycelex)
(Lotrisone)
1
1
1
1
(Spectazole)
(Diflucan)
(Ancobon)
(Grifulvin V)
(Sporanox)
(Kuric)
(Nuzole)
(Nystatin)
(Mycogen II)
(Sodium Thiosulfate/‌sal
Acid)
(Lamisil)
(Vfend)
(Gris-peg)
1
1
1
1
1
1
1
1
1
1
(Grifulvin V)
2
2
2
oral susp
1
1
2
tablet
tablet
PA
Page 26 of 126
D‌rug Name
ANCOBON
CICLODAN
CICLODAN
CLOTRIMAZOLE
CNL 8
DIFLUCAN
ECONAZOLE
NITRATE
ERTACZO
EXELDERM
EXTINA
FIRST-BXN
FIRST-DUKE'S
FIRST-MARY'S
FLUCONAZOLE
GRIFULVIN V
ITRACONAZOLE
KETOCONAZOLE
KETODAN
LAMISIL
LOPROX
LOTRISONE
MENTAX
MICONAZOLE
NITRATE
NAFTIN
NIZORAL A-D
NIZORAL
NYSTATIN
NYSTAT-RX
ONMEL
OXISTAT
PENLAC
SPORANOX
TERBINAFINE HCL
triacetin
VFEND
VUSION
Drug
Tier
3
3
3
3
3
3
3
cream (g)
solution
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
(Triacetin)
3
3
3
3
3
3
3
3
3
3
3
3
3
Page 27 of 126
D‌rug Name
XOLEGEL
amphotericin b
CANCIDAS
MYCAMINE
(Amphotericin B)
Drug
Tier
3
4
4
4
PA
PA
PA
vial: 50mg
Antihistamines
Antihistamines
ALLEGRA-D 12 HOUR
brompheniramine
maleate
brompheniramine tannate
carbinoxamine maleate
cetirizine hcl
CHILDREN'S
CLARITIN
CHILDREN'S ZYRTEC
HIVES RELIEF
CHILDREN'S ZYRTEC
CHILD'S ZYRTEC
ALLERGY
chlormal/‌phenyleph/‌methscop
chlorpheniramine
maleate
chlorpheniramine tannate
CLARITIN
CLARITIN-D 12 HOUR
clemastine fumarate
cyproheptadine hcl
dexchlorpheniramine
maleate
diphenhydramine hcl
doxylamine succinate
fexofenadine hcl
(Bromax)
(Brompheniramine Tannate)
(Palgic)
(Cetirizine HCl)
1
1
tab er 12h: 60mg-120mg
tab er 12h: 6mg
1
1
1
1
1
1
1
(Dallergy)
1
liquid
(Chlor-trimeton)
1
(Myci Chlor-tan)
1
1
1
1
1
1
capsule sa: 8mg; drops,
syrup, tablet, tablet er,
tablet sa
drops: 2mg/‌ml; tablet
(Clemastine Fumarate)
(Cyproheptadine HCl)
(Dexchlorpheniramine
Maleate)
(Diphenhydramine HCl)
(Doxylamine Succinate)
(Fexofenadine HCl)
fexofenadine/‌pseudoephe (Allegra-d 12 Hour)
drine
1
1
1
1
syrup
capsule: 50mg; liquid
oral susp, tab rapdis, tablet:
30mg, 60mg, 180mg
tab er 12h, tab er 24h: 180240mg
Page 28 of 126
D‌rug Name
levocetirizine
dihydrochloride
loratadine
loratadine/‌pseudoephedri
ne
p-epd tan/‌chlor-tan
p-ephed hcl/‌triprolidine
hcl
phenyleph/‌dexchlor/‌meths
copol
phenylephrine
hcl/‌prometh hcl
phenylephrine/‌brompheni
ramine
phenylephrine/‌chlorpheni
ramine
phenylephrine/‌diphenhyd
ramine
phenylephrine/‌dp-hydram
tan
phenylephrine/‌p-tlox
ci/‌cp
phenylephrine/‌pyrilamine
tan
promethazine hcl
pseudoephed/‌chlorphenir
amine
pseudoephedrine
hcl/‌chlor-mal
pseudoephedrine/‌cpm/‌met
hscopol
tripelennamine hcl
triprolidine hcl
ZYRTEC
ZYRTEC-D
brompheniramine
maleate
Drug
Tier
(Xyzal)
1
(Claritin)
(Claritin-d 24 Hour)
1
1
(P-epd Tan/‌chlor-tan)
(Trip-pse)
1
1
(Extendryl)
1
(Phenylephrine HCl/‌prometh
HCl)
(Bromfed)
1
1
cap er 12h
(Phenylephrine/‌chlorphenira
mine)
(Phenylephrine/‌diphenhydra
mine)
(Phenylephrine/‌dp-hydram
Tan)
(Phenylephrine/‌p-tlox Ci/‌cp)
1
drops, syrup
(Phenylephrine/‌pyrilamine
Tan)
(Promethazine HCl)
(Pseudoephed/‌chlorpheniram
ine)
(Pseudoephedrine HCl/‌chlormal)
(Pseudoephedrine/‌cpm/‌meth
scopol)
(Tripelennamine HCl)
(Zymine)
1
(Bromax)
ST
liquid: 10-0.938/‌1
1
1
1
1
1
drops, liquid
1
capsule
1
1
1
1
1
2
tab er 12h: 11mg
Page 29 of 126
D‌rug Name
Drug
Tier
desloratadine
(Clarinex)
2
desloratadine
(Clarinex)
2
fexofenadine hcl
guaifen/‌theop anhyd/‌pephed
p-ephed hcl/‌chlormal/‌bell alk
p-ephed hcl/‌triprolidine
hcl
phenylephrine/‌brompheni
ramine
pseudoephed & triprolid
polist
pseudoephed/‌chlorphenir
amine
ACCUHIST
ALAHIST LQ
ALLEGRA-D 12 HOUR
ALLEGRA-D 24 HOUR
ALLERX 30
ALLERX DF 30
ALLERX DF
ALLERX PE
CLARINEX-D 12 HOUR
(Allegra)
(Guaifen/‌theop Anhyd/‌pephed)
(P-ephed HCl/‌chlor-mal/‌bell
Alk)
(Trip-pse)
2
2
QL: 30 in 30 tablet
days
ST, QL: 30
tab rapdis
in 30 days
tablet: 30mg, 180mg
2
tab er 12h: 90-8-0.24
2
liquid: 10-0.938/‌1
(Zotex-pe)
2
tab er 12h
(Pseudoephed & Triprolid
Polist)
(Pseudoephed/‌chlorpheniram
ine)
2
2
3
3
3
3
3
3
3
3
3
CLARINEX-D 24 HOUR
3
CLARINEX
3
CLEMASTINE
FUMARATE
CYPROHEPTADINE
HCL
DIMENHYDRINATE
DIPHENHYDRAMINE
HCL
3
tab chew
tab er 12h: 60mg-120mg
ST, QL: 60
in 30 days
ST, QL: 60
in 30 days
ST, QL: 30
in 30 days
3
3
3
Page 30 of 126
D‌rug Name
HYDROXYZINE HCL
HYDROXYZINE
PAMOATE
LODRANE 24
LODRANE
PALGIC
PATANASE
phenylephrine/‌brompheni (Vazotab)
ramin
PROTID
RESCON-JR.
RESCON-MX
RYNA-12 S
RYNA-12
SEMPREX-D
TRIP-PSE
TRIPROLIDINE HCL
XYZAL
ZOTEX-PE
ZYMINE DXR
ZYMINE XR
ZYMINE
ZYMINE-D
diphenhydramine hcl
(Benadryl)
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
ST
PA
vial
Anti-infectives (Skin and Mucous Membrane)
Anti-infectives (Skin and Mucous Membrane)
clindamycin phosphate
(Cleocin)
metronidazole
(Metrogel-vaginal)
miconazole nitrate
(Miconazole Nitrate)
miconazole nitrate
(Monistat 3)
sod
(Sod
propion/‌inositol/‌aa14/‌ure Propion/‌inositol/‌aa14/‌urea)
a
terconazole
(Terazol 3)
VANDAZOLE
AVC
CLEOCIN
GYNAZOLE 1
1
1
1
1
1
GF
GF
1
1
2
2
2
GF
GF
GF
GF
GF
GF
GF
supp.vag: 100mg
supp.vag: 200mg
supp.vag
Page 31 of 126
D‌rug Name
CLEOCIN
CLINDESSE
FEM PH
METROGEL-VAGINAL
RELAGARD
TERAZOL 3
TERAZOL 7
Antivirals (Skin and Mucous Membrane)
ABREVA
Drug
Tier
3
3
3
3
3
3
3
GF
GF
GF
GF
GF
GF
GF
cream/‌appl
1
Page 32 of 126
D‌rug Name
Drug
Tier
Antimigraine Agents
Antimigraine Agents
ergotamine
(Ergotamine
tartrate/‌caffeine
Tartrate/‌caffeine)
isomethept/‌acetaminop/‌di (Midrin)
chlphn
naratriptan hcl
(Amerge)
1
1
1
sumatriptan succinate
(Imitrex)
1
(Imitrex)
1
sumatriptan
(Imitrex)
1
dihydroergotamine
mesylate
dihydroergotamine
mesylate
MAXALT MLT
(D.H.E. 45)
2
(Migranal)
2
2
MAXALT
2
RELPAX
2
rizatriptan benzoate
(Maxalt)
2
(Imitrex)
2
zolmitriptan
(Zomig)
2
ALSUMA
3
AMERGE
3
AXERT
3
CAFERGOT
D.H.E.45
3
3
QL: 9 in 30
days
QL: 10 in 30
days
QL: 9 in 30
days
QL: 12 in 30
days
PA
cartridge: 6mg/‌0.5ml; pen
injctr
tablet
ampul
spray/‌pump
QL: 12 in 30
days
QL: 12 in 30
days
QL: 12 in 30
days
QL: 12 in 30
days
QL: 10 in 30 cartridge: 4mg/‌0.5ml
days
QL: 12 in 30
days
ST, QL: 10
in 30 days
ST, QL: 9 in
30 days
ST, QL: 12
in 30 days
PA
Page 33 of 126
D‌rug Name
Drug
Tier
DIHYDROERGOTAMI
NE MESYLATE
ERGOMAR
FROVA
3
IMITREX
3
IMITREX
3
IMITREX
3
MIDRIN
MIGRANAL
SUMAVEL DOSEPRO
3
3
3
TREXIMET
3
ZOMIG ZMT
3
ZOMIG
3
3
3
ST, QL: 9 in
30 days
ST, QL: 10
in 30 days
ST, QL: 12
in 30 days
ST, QL: 9 in
30 days
cartridge, pen injctr, vial
spray
tablet
ST, QL: 10
in 30 days
ST, QL: 9 in
30 days
ST, QL: 12
in 30 days
ST, QL: 12
in 30 days
Antimycobacterials
Antimycobacterials
dapsone
(Dapsone)
ethambutol hcl
(Myambutol)
isoniazid
(Isoniazid)
pyrazinamide
(Pyrazinamide)
rifampin
(Rifadin)
rifampin/‌isoniazid
(Rifampin/‌isoniazid)
rifabutin
MYCOBUTIN
PRIFTIN
SEROMYCIN
DAPSONE
ETHAMBUTOL HCL
MYAMBUTOL
PASER
RIFADIN
RIFAMATE
1
1
1
1
1
1
2
2
2
3
3
3
3
3
3
solution, tablet
capsule
150mg
Page 34 of 126
D‌rug Name
RIFAMPIN
RIFATER
TRECATOR
CAPASTAT SULFATE
SIRTURO
Drug
Tier
3
3
3
4
4
PA
PA
Page 35 of 126
D‌rug Name
Drug
Tier
Antinausea Agents
Antinausea Agents
dimenhydrinate
(Dimenhydrinate)
granisetron hcl
(Granisetron HCl)
granisetron hcl
(Kytril)
1
1
1
meclizine hcl
ondansetron hcl
ondansetron hcl
(Antivert)
(Zofran)
(Zofran)
1
1
1
ondansetron hcl
(Zofran)
1
ondansetron hcl
(Zofran)
1
ondansetron
(Zofran Odt)
1
ondansetron
(Zofran Odt)
1
prochlorperazine maleate
promethazine hcl
trimethobenzamide hcl
trimethobenzamide hcl/‌bcaine
ANZEMET
(Compazine)
(Promethazine HCl)
(Tigan)
(Trimethobenzamide HCl/‌bcaine)
1
1
1
1
dronabinol
ANTIVERT
CESAMET
COMPAZINE
EMEND
(Marinol)
2
2
3
3
3
3
EMEND
3
EMEND
3
MARINOL
MECLIZINE HCL
PROMETHAZINE HCL
3
3
3
QL: 2 in 30
days
QL: 1 in 30
days
QL: 12 in 30
days
QL: 6 in 30
days
QL: 12 in 30
days
QL: 6 in 30
days
tablet
solution
tablet
solution
tablet: 24mg
tablet: 4mg
tablet: 8mg
tab rapdis: 4mg
tab rapdis: 8mg
supp.rect, tablet
capsule
QL: 5 in 30
days
tablet
PA
QL: 1 in 30
days
QL: 2 in 30
days
QL: 3 in 30
days
syrup
capsule: 80mg
cap ds pk
Page 36 of 126
D‌rug Name
Drug
Tier
SANCUSO
3
QL: 1 in 28
days
TIGAN
TRANSDERM-SCOP
TRIMETHOBENZAMID
E HCL
ZOFRAN ODT
3
3
3
3
QL: 5 in 30
days
ZOFRAN
ZOFRAN
3
3
ZUPLENZ
3
ZUPLENZ
3
ALOXI
4
solution
QL: 5 in 30 tablet
days
QL: 12 in 30 film: 4mg
days
QL: 8 in 30 film: 8mg
days
PA
capsule
Antiparasite Agents
Antiparasite Agents
atovaquone/‌proguanil hcl (Malarone)
chloroquine phosphate
(Aralen Phosphate)
hydroxychloroquine
(Plaquenil)
sulfate
mefloquine hcl
(Lariam)
metronidazole
(Flagyl)
paromomycin sulfate
tinidazole
ALINIA
DARAPRIM
mebendazole
atovaquone
quinine sulfate
STROMECTOL
ALBENZA
ARALEN PHOSPHATE
BILTRICIDE
COARTEM
FLAGYL ER
(Paromomycin Sulfate)
(Tindamax)
(Mebendazole)
MEPRON
(Qualaquin)
1
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
capsule, tablet: 250mg,
500mg
750mg/5ml
PA
Page 37 of 126
D‌rug Name
FLAGYL
HALFAN
MALARONE
MEBENDAZOLE
METRONIDAZOLE
PLAQUENIL
PRIMAQUINE
QUALAQUIN
TINDAMAX
YODOXIN
NEBUPENT
Drug
Tier
3
3
3
3
3
3
3
3
3
3
4
PA
PA
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl
(Amantadine HCl)
benztropine mesylate
(Benztropine Mesylate)
bromocriptine mesylate
(Parlodel)
cabergoline
(Cabergoline)
carbidopa/‌levodopa
(Sinemet 10-100)
carbidopa/‌levodopa/‌entac (Stalevo 50)
apone
entacapone
(Comtan)
pramipexole di-hcl
(Mirapex)
ropinirole hcl
(Requip)
selegiline hcl
(Eldepryl)
trihexyphenidyl hcl
(Trihexyphenidyl HCl)
AZILECT
TASMAR
AMANTADINE HCL
BENZTROPINE
MESYLATE
BROMOCRIPTINE
MESYLATE
COMTAN
carbidopa
LODOSYN (Eff 3/1/14 Tier
Change from 3 to 2)
MIRAPEX ER
MIRAPEX
1
1
1
1
1
1
tablet
1
1
1
1
1
2
2
3
3
3
3
2
25mg
3
3
Page 38 of 126
D‌rug Name
Drug
Tier
NEUPRO
3
NEUPRO
3
PARCOPA
PARLODEL
PERGOLIDE
MESYLATE
REQUIP XL
REQUIP
SINEMET 10-100
SINEMET 25-100
SINEMET 25-250
SINEMET CR
STALEVO 100
STALEVO 125
STALEVO 150
STALEVO 200
STALEVO 50
STALEVO 75
ZELAPAR
APOKYN
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
ST
patch td24: 4mg/‌24hr,
6mg/‌24hr, 8mg/‌24hr
patch td24: 1mg/‌24hr,
2mg/‌24hr, 3mg/‌24hr
PA
Antipsychotic Agents
Antipsychotic Agents
chlorpromazine hcl
(Chlorpromazine HCl)
clozapine
(Clozaril)
fluphenazine hcl
(Fluphenazine HCl)
haloperidol lactate
(Haloperidol Lactate)
haloperidol
(Haloperidol)
loxapine succinate
(Loxitane)
olanzapine
(Zyprexa)
perphenazine
(Perphenazine)
quetiapine fumarate
(Seroquel)
risperidone
(Risperdal)
thioridazine hcl
(Thioridazine HCl)
thiothixene
(Navane)
trifluoperazine hcl
(Trifluoperazine HCl)
ziprasidone hcl
(Geodon)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
oral conc., tablet
tablet
elixir, oral conc, tablet
oral conc
tab rapdis, tablet
Page 39 of 126
D‌rug Name
ABILIFY DISCMELT
ABILIFY
clozapine
(Fazaclo)
ORAP
SEROQUEL XR
CHLORPROMAZINE
HCL
CLOZARIL
FANAPT
FAZACLO
GEODON
HALOPERIDOL
INVEGA
LATUDA
LOXITANE
MOBAN
PROCHLORPERAZINE
MALEATE
RISPERDAL M-TAB
RISPERDAL
SAPHRIS
SEROQUEL
THIORIDAZINE
HYDROCHLORIDE
ZYPREXA ZYDIS
ZYPREXA
Drug
Tier
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
ST
ST
tab rapdis
ST
capsule
3
3
3
3
3
3
3
tablet
Antivirals (Systemic)
Antiretrovirals
abacavir sulfate
didanosine
lamivudine
lamivudine/‌zidovudine
nevirapine
stavudine
zidovudine
APTIVUS
APTIVUS
CRIXIVAN
(Ziagen)
(Videx EC)
(Epivir)
(Combivir)
(Viramune)
(Zerit)
(Retrovir)
1
1
1
1
1
1
1
2
2
2
capsule
solution
Page 40 of 126
D‌rug Name
EMTRIVA
EPIVIR HBV
EPIVIR
EPZICOM
INTELENCE
INVIRASE
ISENTRESS
KALETRA
LEXIVA
PREZISTA
RESCRIPTOR
REYATAZ
SELZENTRY
SUSTIVA
abacavir /lamivudine
(TRIZIVIR)
/zidouvudine
TRUVADA
VIDEX
VIRACEPT
VIRAMUNE XR
VIREAD
ZIAGEN
ATRIPLA
COMBIVIR
COMPLERA
EDURANT
NORVIR
RETROVIR
STRIBILD
VIDEX EC
VIRAMUNE
ZERIT
ZIAGEN
FUZEON
Antivirals, Miscellaneous
rimantadine hcl
(Flumadine)
FLUMADINE
Drug
Tier
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
4
150-300mg
solution
capsule, syrup
tablet
PA
1
3
Page 41 of 126
D‌rug Name
Drug
Tier
RELENZA
3
TAMIFLU
3
TAMIFLU
3
foscarnet sodium
(Foscavir)
Hcv Protease Inhibitors
INCIVEK
VICTRELIS
Interferons
INFERGEN
INTRON A
PEGASYS PROCLICK
PEGASYS
PEGINTRON REDIPEN
PEGINTRON
SYLATRON 4-PACK
Nucleosides and Nucleotides
acyclovir
(Zovirax)
ribavirin
(Rebetol)
valacyclovir hcl
(Valtrex)
famciclovir
(Famvir)
RIBATAB
ribavirin
(Copegus)
4
QL: 20 in
180 days
QL: 10 in
180 days
QL: 180 in
180 days
PA
4
4
PA
PA
4
4
4
4
4
4
4
PA
PA
PA
PA
PA
PA
PA
ribavirin
VALCYTE
ACYCLOVIR
BARACLUDE
COPEGUS
FAMVIR
HEPSERA
REBETOL
RIBATAB
2
2
3
3
3
3
3
3
3
PA
3
PA
(Ribatab)
RIBAVIRIN
1
1
1
2
2
2
capsule
susp recon
PA
capsule: 200mg
PA
PA
tab ds pk: 600-600mg
capsule: 200mg; tab ds pk:
400-400mg, 600-400mg;
tablet
tab ds pk: 200-400mg
ST
PA
PA
tab ds pk: 400-400mg,
600-400mg; tablet
Page 42 of 126
D‌rug Name
TYZEKA
VALTREX
ZOVIRAX
acyclovir sodium
cidofovir
(Acyclovir Sodium)
(Vistide)
Drug
Tier
3
3
3
4
4
ST
PA
PA
Blood Products/‌modifiers/‌volume Expanders
Anticoagulants
heparin sodium,porcine
(Hep-lock)
1
vial: 5000/‌ml, 10000/‌ml,
20000/‌ml
disp syrin: 5000/‌0.5ml;
vial
heparin
(Monoject Prefill Advanced)
sodium,porcine/‌pf
warfarin sodium
(Coumadin)
COUMADIN
XARELTO
ELIQUIS
PRADAXA
WARFARIN SODIUM
ARIXTRA
enoxaparin sodium
(Lovenox)
fondaparinux sodium
(Arixtra)
FRAGMIN
LOVENOX
Blood Formation Modifiers
NEULASTA
NEUPOGEN
ARANESP
EPOGEN
LEUKINE
MOZOBIL
NEUPOGEN
1
3
3
4
4
4
4
4
PA
PA
PA
PA
PA
PA
PA
OMONTYS
PROCRIT
PROMACTA
Hematologic Agents, Miscellaneous
aminocaproic acid
(Amicar)
anagrelide hcl
(Agrylin)
4
4
4
PA
PA
PA
1
2
2
3
3
3
4
4
4
4
4
1
1
tablet
PA
PA
disp syrin: 480mcg/‌0.8
disp syrin: 300mcg/‌0.5;
vial
solution, tablet
Page 43 of 126
D‌rug Name
tranexamic acid
(Lysteda)
Drug
Tier
2
AGRYLIN
LYSTEDA
3
3
tranexamic acid
(Tranexamic Acid)
Platelet-aggregation Inhibitors
cilostazol
(Pletal)
clopidogrel bisulfate
(Plavix)
dipyridamole
(Persantine)
pentoxifylline
(Trental)
ticlopidine hcl
(Ticlid)
AGGRENOX
BRILINTA
EFFIENT
PERSANTINE
PLAVIX
PLETAL
TRENTAL
4
QL: 30 in 30 tablet
days
QL: 30 in 30
days
PA
vial
1
1
1
1
1
3
3
3
3
3
3
3
Cardiovascular Agents
Alpha-adrenergic Agents
clonidine hcl
(Catapres)
clonidine
(Catapres-tts 1)
doxazosin mesylate
(Cardura)
guanfacine hcl
(Tenex)
methyldopa
(Aldomet)
methyldopa/‌hydrochlorot (Methyldopa/‌hydrochlorothi
hiazide
azide)
midodrine hcl
(Proamatine)
prazosin hcl
(Minipress)
DIBENZYLINE
CARDURA XL
CARDURA
CATAPRES
CATAPRES-TTS 1
CATAPRES-TTS 2
CATAPRES-TTS 3
1
1
1
1
1
1
1
1
2
3
3
3
3
3
3
Page 44 of 126
D‌rug Name
clonidine
(Clonidine
hcl/‌chlorthalidone
HCl/‌chlorthalidone)
CLORPRES
MINIPRESS
TENEX
methyldopate hcl
(Methyldopate HCl)
Angiotensin II Receptor Antagonists
irbesartan
(Avapro)
irbesartan/‌hydrochlorothi (Avalide)
azide
losartan potassium
(Cozaar)
losartan/‌hydrochlorothiaz (Hyzaar)
ide
valsartan/‌hydrochlorothi (Diovan HCT)
azide
BENICAR HCT
BENICAR
candesartan cilexetil
(Atacand)
candesartan/‌hydrochlorot (Atacand HCT)
hiazid
eprosartan mesylate
(Teveten)
ATACAND HCT
ATACAND
AVALIDE
AVAPRO
COZAAR
DIOVAN HCT
DIOVAN
EDARBI
EDARBYCLOR
HYZAAR
telmisartan/hctz
MICARDIS HCT (Eff 3/1/14
telmisartan
MICARDIS (Eff 3/1/14 Tier
Change from 3 to 2)
TEVETEN HCT
TEVETEN
TRIBENZOR
Drug
Tier
3
3
3
3
4
PA
1
1
ST
ST
1
1
1
ST
2
2
2
2
ST
ST
ST
2
3
3
3
3
3
3
3
3
3
3
2
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
40-12.5mg, 80mg-25mg
2
ST
20mg, 40mg, 80mg
3
3
3
ST
ST
ST
Page 45 of 126
D‌rug Name
telmisartan/amlodipine
TWYNSTA (Eff 3/1/14 Tier
Change from 3 to 2)
Angiotensin-Converting Enzyme Inhibitors
benazepril hcl
(Lotensin)
benazepril/‌hydrochlorothi (Lotensin HCT)
azide
captopril
(Capoten)
captopril/‌hydrochlorothia (Capozide)
zide
enalapril maleate
(Vasotec)
enalapril/‌hydrochlorothia (Vaseretic)
zide
fosinopril sodium
(Monopril)
fosinopril/‌hydrochlorothi (Monopril HCT)
azide
lisinopril
(Zestril)
lisinopril/‌hydrochlorothia (Prinzide)
zide
moexipril hcl
(Univasc)
moexipril/‌hydrochlorothi (Uniretic)
azide
perindopril erbumine
(Aceon)
quinapril hcl
(Accupril)
quinapril/‌hydrochlorothia (Accuretic)
zide
ramipril
(Altace)
trandolapril
(Mavik)
ACCUPRIL
ACCURETIC
ACEON
ALTACE
ENALAPRIL
MALEATE
LISINOPRIL
LOTENSIN HCT
LOTENSIN
MAVIK
PRINIVIL
Drug
Tier
2
ST
80mg–10mg, 80mg–5mg,
40mg–10mg, 40mg–5mg
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
Page 46 of 126
D‌rug Name
PRINZIDE
TARKA
UNIRETIC
UNIVASC
VASERETIC
VASOTEC
ZESTORETIC
ZESTRIL
Antiarrhythmic Agents
amiodarone hcl
(Cordarone)
disopyramide phosphate (Norpace)
flecainide acetate
(Tambocor)
mexiletine hcl
(Mexitil)
propafenone hcl
(Rythmol)
quinidine gluconate
(Quinidine Gluconate)
quinidine sulfate
(Quinidine Sulfate)
MULTAQ
TIKOSYN
AMIODARONE HCL
CORDARONE
MEXILETINE HCL
NORPACE CR
NORPACE
RYTHMOL SR
RYTHMOL
TAMBOCOR
procainamide hcl
(Procainamide HCl)
Beta-Adrenergic Blocking Agents
acebutolol hcl
(Sectral)
atenolol
(Tenormin)
atenolol/‌chlorthalidone
(Tenoretic 50)
betaxolol hcl
(Kerlone)
bisoprolol fumarate
(Zebeta)
bisoprolol fumarate/‌hctz (Ziac)
carvedilol
(Coreg)
labetalol hcl
(Trandate)
metoprolol succinate
(Toprol XL)
metoprolol tartrate
(Lopressor)
Drug
Tier
3
3
3
3
3
3
3
3
1
1
1
1
1
1
1
2
2
3
3
3
3
3
3
3
3
4
1
1
1
1
1
1
1
1
1
1
tablet
tablet er
PA
vial: 500mg/‌ml
tablet
tablet
Page 47 of 126
D‌rug Name
metoprolol/‌hydrochloroth
iazide
nadolol
nadolol/‌bendroflumethiaz
ide
pindolol
propranolol hcl
propranolol/‌hydrochlorot
hiazid
sotalol hcl
timolol maleate
COREG CR
DUTOPROL
Drug
Tier
(Lopressor HCT)
1
(Corgard)
(Corzide)
1
1
(Pindolol)
(Propranolol HCl)
(Propranolol/‌hydrochlorothia
zid)
(Betapace)
(Timolol Maleate)
1
1
1
ACEBUTOLOL HCL
ATENOLOL
BETAPACE
BYSTOLIC
COREG
CORGARD
CORZIDE
DUTOPROL
INDERAL LA
INNOPRAN XL
KERLONE
LEVATOL
LOPRESSOR HCT
LOPRESSOR
METOPROLOL
TARTRATE
PROPRANOLOL HCL
SECTRAL
TENORETIC 100
TENORETIC 50
TENORMIN
TIMOLOL MALEATE
TOPROL XL
TRANDATE
1
1
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
cap sa 24h, solution, tablet
tab er 24h: 50-12.5mg,
100-12.5mg
tab er 24h: 25-12.5mg
tablet
tablet
Page 48 of 126
D‌rug Name
Drug
Tier
ZEBETA
ZIAC
Calcium-channel Blocking Agents
diltiazem hcl
(Cardizem CD)
3
3
verapamil hcl
1
(Calan)
CALAN SR
CALAN
CARDIZEM CD
CARDIZEM LA
CARDIZEM
DILACOR XR
DILTIAZEM HCL
TIAZAC
VERAPAMIL HCL
VERELAN PM
VERELAN
Cardiovascular Agents, Miscellaneous
digoxin
(Lanoxin)
DIGOXIN
hydralazine hcl
(Apresoline)
isoxsuprine hcl
(Isoxsuprine HCl)
papaverine hcl
(Papaverine HCl)
reserpine
(Reserpine)
EPIPEN 2-PAK
EPIPEN JR 2-PAK
AUVI-Q
CLONIDINE HCL
DEMSER
DIGOXIN
DIPYRIDAMOLE
GUANABENZ
ACETATE
GUANFACINE
HYDROCHLORIDE
HYDRALAZINE HCL
1
cap er 12h, cap er 24h, cap
er deg, capsule er, tab er
24h, tablet
cap24h pct, cap24h pel,
tablet, tablet er
3
3
3
3
3
3
3
3
3
3
3
1
1
1
1
1
1
2
2
3
3
3
3
3
3
tablet
solution
tablet
capsule er, tablet
powder
3
3
Page 49 of 126
D‌rug Name
LANOXIN
RANEXA
Dihydropyridines
amlodipine besylate
amlodipine
besylate/‌benazepril
felodipine
isradipine
nicardipine hcl
nifedipine
nimodipine
nisoldipine
AZOR
ADALAT CC
AMLODIPINE
BESILATE
CARDENE SR
EXFORGE HCT
EXFORGE
LOTREL
NIFEDIPINE
NIMOTOP
NORVASC
NYMALIZE
PROCARDIA XL
PROCARDIA
SULAR
Diuretics
amiloride hcl
amiloride/‌hydrochlorothi
azide
bumetanide
chlorothiazide
chlorthalidone
furosemide
hydrochlorothiazide
indapamide
methyclothiazide
Drug
Tier
3
3
(Norvasc)
(Lotrel)
1
1
(Plendil)
(Dynacirc)
(Nicardipine HCl)
(Procardia XL)
(Nimotop)
(Sular)
1
1
1
1
1
1
2
3
3
3
3
3
3
3
3
3
3
3
3
3
(Midamor)
(Amiloride/‌hydrochlorothiaz
ide)
(Bumex)
(Chlorothiazide)
(Chlorthalidone)
(Lasix)
(Hydrochlorothiazide)
(Lozol)
(Methyclothiazide)
tablet
capsule
ST
ST
ST
1
1
1
1
1
1
1
1
1
tablet
solution, tablet
Page 50 of 126
D‌rug Name
Drug
Tier
metolazone
torsemide
triamterene/‌hydrochlorot
hiazid
AMILORIDE HCL
DEMADEX
DIURIL
DYAZIDE
DYRENIUM
EDECRIN
HYDROCHLOROTHIA
ZIDE
LASIX
MAXZIDE-25 MG
MAXZIDE
MICROZIDE
MIDAMOR
NATURETIN-5
ZAROXOLYN
SAMSCA
Dyslipidemics
amlodipine/‌atorvastatin
atorvastatin calcium
(Zaroxolyn)
(Demadex)
(Maxzide)
(Caduet)
(Lipitor)
1
1
cholestyramine (with
sugar)
cholestyramine/‌aspartam
e
colestipol hcl
fenofibrate
nanocrystallized
fenofibrate
fenofibrate,micronized
(Questran)
1
(Questran Light)
1
(Colestid)
(Tricor)
1
1
(Lofibra)
(Antara)
1
1
fenofibric acid
fluvastatin sodium
(Fibricor)
(Lescol)
1
1
gemfibrozil
(Lopid)
1
1
1
1
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
PA
QL: 30 in 30
days
capsule: 67mg, 134mg,
200mg
QL: 30 in 30
days
Page 51 of 126
D‌rug Name
Drug
Tier
lovastatin
(Mevacor)
1
niacin
pravastatin sodium
(Niacin)
(Pravachol)
1
1
simvastatin
(Zocor)
1
fenofibrate,micronized
LOFIBRA
LOFIBRA
LOVAZA
NIASPAN
SIMCOR
(Antara)
2
2
2
2
2
2
TRICOR
ZETIA
ADVICOR
2
2
3
ADVICOR
3
ADVICOR
3
ALTOPREV
3
ANTARA
CADUET
CHOLESTYRAMINE
RESIN
COLESTID
CRESTOR
3
3
3
FENOGLIDE
FIBRICOR
LESCOL XL
3
3
3
LESCOL
3
3
3
QL: 30 in 30
days
QL: 30 in 30
days
QL: 30 in 30
days
capsule
tablet
ST, QL: 60
in 30 days
ST
QL: 30 in 30
days
QL: 60 in 30
days
ST, QL: 30
in 30 days
ST, QL: 30
in 30 days
tbmp 24hr: 500mg-20mg,
1000-40mg
tbmp 24hr: 1000-20mg
tbmp 24hr: 750mg-20mg
ST, QL: 30
in 30 days
ST, QL: 30
in 30 days
ST, QL: 30
in 30 days
Page 52 of 126
D‌rug Name
Drug
Tier
LIPITOR
3
LIPOFEN
LIPTRUZET
LIVALO
3
3
3
LOPID
MEVACOR
3
3
PRAVACHOL
3
QUESTRAN LIGHT
SIMVASTATIN
TRIGLIDE
TRILIPIX
VYTORIN
WELCHOL
ZOCOR
3
3
3
3
3
3
3
Renin-Angiotensin-Aldosterone System Inhibitors
eplerenone
(Inspra)
spironolact/‌hydrochlorot (Aldactazide)
hiazid
spironolactone
(Aldactone)
TEKTURNA HCT
TEKTURNA
ALDACTAZIDE
ALDACTONE
AMTURNIDE
INSPRA
SPIRONOLACTONE
TEKAMLO
Vasodilators
isosorbide dinitrate
(Isordil)
isosorbide mononitrate
(Imdur)
minoxidil
(Minoxidil)
nitroglycerin
(Nitro-dur)
1
1
1
2
2
3
3
3
3
3
3
1
1
1
1
ST, QL: 30
in 30 days
ST, QL: 30
in 30 days
ST, QL: 60
in 30 days
ST, QL: 30
in 30 days
ST
ST, QL: 30
in 30 days
ST
ST
ST
ST
ST
ST
capsule er, patch td24,
spray
Page 53 of 126
D‌rug Name
Drug
Tier
DILATRATE-SR
ISORDIL
NITRO-BID
NITRO-DUR
2
2
2
2
NITROLINGUAL
NITROMIST
NITROSTAT
BIDIL
IMDUR
ISOCHRON
ISORDIL TITRADOSE
NITRO-DUR
2
2
2
3
3
3
3
3
PROGLYCEM
3
patch td24: 0.3mg/‌hr,
0.8mg/‌hr
patch td24: 0.1mg/‌hr,
0.2mg/‌hr, 0.4mg/‌hr,
0.6mg/‌hr
Central Nervous System Agents
Central Nervous System Agents
caffeine citrated
(Cafcit)
dexmethylphenidate hcl
(Focalin)
dextroamphetamine
(Dexedrine)
sulfate
dextroamphetamine/‌amph (Adderall)
etamine
lithium carbonate
(Eskalith)
lithium citrate
(Lithium Citrate)
METADATE ER
methamphetamine hcl
(Desoxyn)
METHYLIN
methylphenidate hcl
(Ritalin)
dextroamphetamine
sulfate
dextroamphetamine/‌amph
etamine
methylphenidate hcl
ADDERALL XR
ADDERALL
1
1
1
solution
capsule er, tablet: 5mg,
10mg
tablet
1
1
1
1
1
1
1
PA
(Dextroamphetamine
Sulfate)
(Adderall XR)
2
cpmp 30-70, solution,
tablet, tablet er
solution
2
cap er 24h
(Concerta)
2
3
3
cpmp 50-50, tab er 24
Page 54 of 126
D‌rug Name
CAFCIT
CAFFEINE CITRATE
CONCERTA
DAYTRANA
DESOXYN
DEXEDRINE
dextroamphetamine
sulfate
FOCALIN XR
FOCALIN
INTUNIV
(Dextrostat)
Drug
Tier
3
3
3
3
3
3
3
3
3
3
KAPVAY
KAPVAY
3
3
LITHIUM CITRATE
TETRAHYDRATE
LITHOBID
METADATE CD
NUEDEXTA
PRIMIDONE
QUILLIVANT XR
RITALIN LA
RITALIN
RITALIN-SR
SAVELLA
3
STRATTERA
3
VYVANSE
3
ZENZEDI
AMPYRA
RILUTEK
riluzole
XENAZINE
3
4
4
4
4
3
3
3
3
3
3
3
3
3
(Rilutek)
solution
PA
tablet: 5mg, 10mg
QL: 30 in 30
days
tb er dspk
QL: 60 in 30 tab er 12h
days
PA
QL: 60 in 30
days
QL: 30 in 30
days
QL: 30 in 30
days
PA
PA
PA
PA
Contraceptives
Contraceptives
Page 55 of 126
D‌rug Name
AMETHYST
desogestrel-ethinyl
estradiol
desog-et estra/‌ethin estra
ethinyl
estradiol/‌drospirenone
ethynodiol d-ethinyl
estradiol
GENERESS FE
levonorgestrel
levonorgestrel-eth
estradiol
l-norgest-eth estr/‌ethin
estra
noreth a-et estra/‌fe
fumarate
noreth-ethinyl
estradiol/‌iron
norethindrone a-e
estradiol
norethindrone
norethindrone-ethinyl
estrad
norethindrone-mestranol
norgestimate-ethinyl
estradiol
norgestrel-ethinyl
estradiol
LO LOESTRIN FE
NUVARING
ORTHO EVRA
ORTHO TRI-CYCLEN
LO
ORTHO TRI-CYCLEN
ANGELIQ
BEYAZ
BREVICON
CHATEAL
Drug
Tier
(Desogen)
1
1
(Mircette)
(Yaz)
1
1
(Demulen 1/‌50-28)
1
(Plan B)
(Chateal)
1
1
1
(Seasonique)
1
(Loestrin Fe)
1
(Femcon Fe)
1
(Loestrin)
1
(Nor-Q-D)
(Modicon)
1
1
(Ortho-novum)
(Ortho-cyclen)
1
1
(Ovral-21)
1
2
2
2
2
tablet: 0.75mg, 1.5mg
GF
2
3
3
3
3
Page 56 of 126
D‌rug Name
CYCLESSA
DEMULEN 1-50-21
DESOGEN
ELLA
ESTROSTEP FE
FEMCON FE
levonorgestrel
LOESTRIN 24 FE
LOESTRIN FE
LOESTRIN
LOSEASONIQUE
MICRONOR
MINASTRIN 24 FE
MIRCETTE
MODICON
NATAZIA
NORDETTE-28
NORINYL 1+35
NORINYL 1+50
NOR-Q-D
ORTHO-CEPT
ORTHO-CYCLEN
ORTHO-NOVUM
OVCON-35
PLAN B ONE-STEP
QUARTETTE
SAFYRAL
SEASONIQUE
TRI-NORINYL
YASMIN 28
YAZ
(Plan B)
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
tablet: 1.5mg
GF
Cough And Cold Products
Cough And Cold Products
benzonatate
(Tessalon)
brompheniramin/‌pe/‌codei (Brompheniramin/‌pe/‌codeine
ne
)
brompheniramin/‌pe/‌dextr (Ala-hist Dm)
omethor
1
1
1
Page 57 of 126
D‌rug Name
bromphenrm/‌pseudoeph/‌d
ihydrocd
car-b-pen ta/‌chlor-tan
car-b-pen
ta/‌phenylephrine/‌pyr
chlorpheniramine/‌codein
e phos
dihydrocodeine/‌guaifenes
in
dm/‌phenyleph/‌chlorpheni
ramine
d-methorphan hb/‌p-epd
hcl/‌bpm
d-methorphan hb/‌p-ephed
hcl/‌cp
d-methorphan
hb/‌prometh hcl
guaifen/‌dm hb/‌pephedrine/‌bpm
guaifen/‌d-methorphan
hb/‌pe/‌bpm
guaifenesin
guaifenesin/‌codeine
phosphate
Drug
Tier
(Bromphenrm/‌pseudoeph/‌dih
ydrocd)
(Trionate)
(Tussi-12d)
1
(Notuss Ac)
1
(Dihydrocodeine/‌guaifenesin
)
(Accuhist Pdx)
1
(Prohist Dm)
1
drops: 3-3.5-1/‌ml; liquid:
15-5-2mg/‌5; syrup
drops
(D-methorphan Hb/‌p-ephed
HCl/‌cp)
(D-methorphan Hb/‌prometh
HCl)
(Guaifen/‌dm Hb/‌pephedrine/‌bpm)
(Guaifen/‌d-methorphan
Hb/‌pe/‌bpm)
(Robitussin Mucus-chest
Congest)
(Guaifenesin/‌codeine
Phosphate)
1
drops
1
1
1
1
1
1
1
1
guaifenesin/‌dextromethor (G-zyncof)
phan
guaifenesin/‌dm/‌pseudoep (Poly-vent Dm)
hedrine
1
guaifenesin/‌dmethorphan hb/‌pe
guaifenesin/‌hydrocodone
bit
guaifenesin/‌p-ephed
hcl/‌cod
guaifenesin/‌phenylephrin
e hcl
(Deconex Dmx)
1
(Guaifenesin/‌hydrocodone
Bit)
(Guaifenesin/‌p-ephed
HCl/‌cod)
(Maxiphen)
1
1
liquid: 100-10mg/‌5, 20010mg/‌5, 300-10mg/‌5;
tablet
liquid, oral susp: 175-1530; tablet: 400-15-45, 40020-40
1
1
Page 58 of 126
D‌rug Name
guaifenesin/‌pseudoephedr
ne hcl
hydrocodone
bit/‌homatrop me-br
hydrocodone/‌chlorphen
polis
p-ephed
hcl/‌codeine/‌guaifen
p-ephed hcl/‌hydrocodone
bit
phenylephrine/‌dhcodeine
bt/‌cp
promethazine hcl/‌codeine
promethazine/‌phenyleph/‌
codeine
pseudoephedrine
hcl/‌codeine
pyrilamine/‌pe/‌dextrometh
orphan
VITUZ
ALDEX GS DM
ALDEX GS
bromphenira/‌pseudoephe
d/‌codein
BRONKIDS
DESPEC DM
DESPEC-EXP
hcl/‌cp
guaifenesin/‌codeine
phosphate
guaifenesin/‌dm/‌pseudoep
hedrine
M-CLEAR WC
M-END DM
M-END PE
M-END WC
ACCUHIST DM
Drug
Tier
(Poly-vent Ir)
1
(Hycodan)
1
(Tussionex)
1
(Tusnel C)
1
(P-ephed HCl/‌hydrocodone
Bit)
(Despec-pd)
1
(Promethazine HCl/‌codeine)
(Promethazine/‌phenyleph/‌co
deine)
(Notuss Dc)
1
1
(Pyrilamine/‌pe/‌dextromethor
phan)
1
(Bromphenira/‌pseudoephed/‌
codein)
syrup: 30-10-100
1
1
1
2
2
2
(Pediacare)
2
2
2
2
syrup, tab chew
(Myci-gc)
2
capsule, liquid: 225-7.5/‌5
(Poly-vent Dm)
2
tablet: 400-20-60
2
2
2
2
3
Page 59 of 126
D‌rug Name
ACCUHIST PDX
ALA-HIST AC
ALAHIST DHC
ALA-HIST DM
ALLFEN CD
ALLFEN CDX
ALLFEN DM
AMBIFED CD
AMBIFED CDX
AMBIFED DM
AMBIFED-G CD
AMBIFED-G CDX
BRONCOTRON-D
BRONCOTRON-D
BRONTUSS SF
BROVEX CB
BROVEX CBX
BROVEX PB C
BROVEX PB CX
BROVEX PEB DM
BROVEX PSB DM
CARBAPHEN 12 PED
CARBAPHEN 12
CARBAPHEN 12
CARBATUSS-12
CARBATUSS-CL
COTAB A
COTAB AX
COTABFLU
DESPEC
DESPEC-DM
DESPEC-PDC
d-methorphan hb/‌p-epd
hcl/‌bpm
DONATUSS DC
DONATUSSIN DM
DURAFLU
DURATUSS AC 12
(Rondec-dm)
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
oral susp: 200-20-30
oral susp: 200-20-5/‌5
oral susp: 4-10-27.5
oral susp: 60-20-8/‌5
syrup: 10-30-2/‌5
3
3
3
3
Page 60 of 126
D‌rug Name
ENTEX
GILPHEX TR
GILTUSS PEDIATRIC
GILTUSS TR
GILTUSS
LORTUSS EX
MAXIFED CD
MAXIFED CDX
MAXIFED-G CD
MAXIFED-G CDX
MAXIFLU CD
MAXIFLU CDX
MAXIPHEN CD
MAXIPHEN CDX
MAXIPHEN DM
NEO DM
NEO DM
NOTUSS-NX
NOTUSS-NXD
PANATUSS DXP
PEDIATRIC
PANATUSS DXP
PEDIATEX TDM
PHENFLU CD
PHENFLU CDX
POLY-TUSSIN AC
POLY-TUSSIN DHC
PRO-CLEAR AC
PROLEX DMX
PRO-RED AC
RESPA C&C IR
RYDEX G
RYNA-12X
RYNATUSS
SUTTAR-2
SUTTAR-SF
TESSALON PERLE
TESSALON
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
drops
liquid
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Page 61 of 126
D‌rug Name
TUSNEL C
TUSNEL PEDIATRIC
TUSNEL-DM
PEDIATRIC
TUSSI-12D
TUSSICAPS
TUSSIGON
TUSSIONEX
TUSSI-PRES
PEDIATRIC
TUSSI-PRES
VANACOF CD
VANACOF DX
VANACOF
VAZOTAN
Z-COF I
Z-DEX
ZODRYL AC 25
ZODRYL AC 30
ZODRYL AC 35
ZODRYL AC 40
ZODRYL AC 50
ZODRYL AC 60
ZODRYL AC 80
ZODRYL DAC 50
ZODRYL DAC 60
ZODRYL DAC 80
ZODRYL DEC 25
ZODRYL DEC 30
ZODRYL DEC 35
ZODRYL DEC 40
ZODRYL DEC 50
ZODRYL DEC 60
ZODRYL DEC 80
ZONATUSS
ZOTEX-C
ZOTEX-D
ZOTEX-D
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
liquid: 100-15-8.5
liquid: 7.5-8-20/‌5
Page 62 of 126
D‌rug Name
ZOTEX-EX
Z-TUSS AC
ZUTRIPRO
Drug
Tier
3
3
3
Dental And Oral Agents
Dental And Oral Agents
cevimeline hcl
(Evoxac)
chlorhexidine gluconate (Peridex)
pilocarpine hcl
(Salagen)
sodium fluoride
(Control Rx)
stannous fluoride
(Gel-kam)
triamcinolone acetonide (Triamcinolone Acetonide)
APHTHASOL
EVOXAC
NAFRINSE DAILYNEUTRAL
ORAVIG
PERIDEX
PHOS-FLUR
PREVIDENT 5000 PLUS
PREVIDENT 5000
SENSITIVE
PREVIDENT
SALAGEN
KEPIVANCE
1
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
4
PA
Dermatological Agents
Dermatological Agents, Other
aluminum chloride
(Drysol)
ammonium lactate
(Lac-hydrin)
benzoyl peroxide&skin
(Brevoxyl-4)
cleansr5
benzoyl peroxide
(Delos)
BENZOYL PEROXIDE
calcipotriene
diphenhydramine hcl
fluorouracil
(Dovonex)
(Diphenhydramine HCl)
(Efudex)
1
1
1
1
cleanser: 4%, 4.25%, 6%,
7%, 8%, 9%; foam, gel
(gram): 5%, 10%; gel
alcohl, kit, lotion
1
1
1
1
Page 63 of 126
D‌rug Name
Drug
Tier
imiquimod
iodine/‌potassium iodide
lidocaine hcl
phenazopy
hcl/‌hyoscy/‌butabarb
podofilox
podophyllum resin
pramoxine hcl
salicylic acid
(Aldara)
(Iodine/‌potassium Iodide)
(Lidamantle)
(Pyrelle Hb)
1
1
1
1
(Condylox)
(Pododerm)
(Pramoxine HCl)
(Salex)
1
1
1
1
salicylic acid/‌ammon
lact/‌aloe
salicylic acid/‌ceramide cmb
#1
salicylic acid/‌sulfur
sulfacet sod/‌sulfur/‌witch haz
sulfacetamd/‌sulfr/‌sknclnsr10
(Salkera)
1
(Salex)
1
(Salicylic Acid/‌sulfur)
(Plexion Sct)
(Sulfacetamd/‌sulfr/‌skncln
sr10)
sulfacetamide sodium
(Sulfacetamide Sodium)
sulfacetamide sodium/‌sulfur (Avar)
1
1
1
sulfacetamide sodium/‌urea
trypsin/‌balsam peru/‌castor
oil
urea
(Rosula Ns)
(Xenaderm)
1
1
(Aluvea)
1
urea/‌lactic ac/‌zn
undecylenate
urea/‌lactic acid/‌salicyl acid
acyclovir
ANACAINE
benzoyl peroxide
(Kerol Zx)
1
(Kerol)
(Zovirax)
1
2
2
2
calcitriol
DENAVIR
(Vectical)
(Benzac Ac)
1
1
cream (g), foam: 6%; gel
(gram), liquid, lotion, med.
soap, shampoo
combo. pkg, kit clcmer:
6%
cleanser: 10-5%(w/‌w);
cream (g): 10-5%(w/‌w)
oint. (g): 90u-87/‌g; spray
cream (g): 20%, 40%,
45%, 50%; foam, gel (ml),
lotion, nl fm susp, sol/‌pf
app
eml md pmp, emulsn(g):
50%; sol/‌pf app
cleanser: 5%; gel (gram):
4%, 8%
2
2
Page 64 of 126
D‌rug Name
Drug
Tier
isotretinoin
mafenide acetate
silver nitrate applicator
sulfacetamide sodium/‌sulfur
(Accutane)
(Mafenide Acetate)
(Silver Nitrate Applicator)
(Avar)
2
2
2
2
sulfacetm
na/‌avobenzone/‌sulfur
XERAC AC
8-MOP
ABSORICA
ACZONE
ALCORTIN A
ALDARA
ALUVEA
ANTHRALIN
AVAR-E LS CREAM
AZELEX
BENSAL HP
BENZAC AC
BENZAC W 10
BENZAC W 2.5
BENZAC W 5
BENZEFOAM ULTRA
CARAC
CETACAINE
ANESTHETIC
CETACAINE
CLARIFOAM EF
CLARIS
CLEARPLEX V
CLEARPLEX X
CONDYLOX
DEL-AQUA-5
DELOS
DESQUAM-X
DOVONEX
DRITHOCREME HP
DRYSOL
(Rosac)
2
PA
cleanser: 10-5%(w/‌w);
med. pad, suspension
cream (g): 10%-5%
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
oint. (g), spray
Page 65 of 126
D‌rug Name
EFUDEX
EMERSAL
EXACTACAIN
FINACEA PLUS
FINACEA
FLUOROPLEX
GORDOFILM
GORDO-UREA
HYDRO 35
INOVA 4-1
INOVA 8-2
KERAFOAM
KERALYT SCALP
KERALYT
KEROL AD
KEROL ZX
LAC-HYDRIN
NEOBENZ MICRO
OXSORALEN-ULTRA
PACNEX HP
PACNEX LP
PACNEX MX
PACNEX
PANOXYL 10
PANOXYL 5
PANOXYL AQ 2.5
PANOXYL AQ 5
PANRETIN
PHENAZOPYRIDINE HCL
PICATO
PLEXION
PRUDOXIN
REGRANEX
RIMSO-50
ROSAC
ROSAC
ROSANIL
ROSANIL
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
cleanser
cream (g)
cleanser
kit
Page 66 of 126
D‌rug Name
ROSULA CLK
ROSULA
ROSULA
SALACYN
SALEX
SALEX
SALKERA
SANTYL
SILVER SULFADIAZINE
SORIATANE
SORILUX
sulfacetamide
sod/‌sulfur/‌urea
SUMAXIN TS
SUMAXIN
(Claris)
TACLONEX (Eff 3/1/14
calcipotriene/betamethasone Tier Change from 3 to 2)
trypsin/‌balsam peru/‌castor (Xenaderm)
oil
UMECTA PD
UMECTA
URAMAXIN GT
URAMAXIN
VANOXIDE-HC
VECTICAL
VENELEX
VEREGEN
VIRASAL
XENADERM
XERESE
X-VIATE
ZONALON
ZOVIRAX
ZYCLARA
AMEVIVE
Dermatological Antibacterials
bacitracin
(Bacitracin)
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
cleanser, gel (ml)
foam
combo. pkg, kit clcmer
shampoo
cleanser: 10%-4%-10%
3
3
2
0.005-.064
3
oint. (g): 90u-87/‌g
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
PA
1
Page 67 of 126
D‌rug Name
Drug
Tier
clindamycin phos/‌benzoyl
perox
clindamycin phosphate
erythromycin
base/‌ethanol
erythromycin/‌benzoyl
peroxide
gentamicin sulfate
metronidazole
(Benzaclin)
1
(Cleocin T)
(Emgel)
1
1
(Benzamycin)
1
(Gentamicin Sulfate)
(Vitazol)
1
1
mupirocin
neomy sulf/‌bacitrac
zn/‌poly
selenium sulfide
silver nitrate
silver sulfadiazine
THERMAZENE
metronidazole
mupirocin calcium
NORITATE
NYDAMAX
ACANYA
AKNE-MYCIN
ALTABAX
BACITRACIN
BACTROBAN NASAL
BACTROBAN
BACTROBAN
BENZACLIN
BENZAMYCIN
CENTANY AT
CENTANY
CLEOCIN T
CLINDACIN P
CLINDAGEL
CORTISPORIN
CORTISPORIN
(Centany)
(Neosporin)
1
1
(Selenium Sulfide)
(Silver Nitrate)
(Silvadene)
(Klaron)
1
1
1
1
1
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
(Metronidazole)
(Bactroban)
cream (g), gel (gram),
lotion
suspension
oint. (g)
gel w/‌pump
cream (g)
oint. (g), oint.(gm)
cream (g)
oint. (g)
Page 68 of 126
D‌rug Name
Drug
Tier
DEL-MYCIN
DUAC CS
ERYGEL
EVOCLIN
KLARON
METROCREAM
METROGEL
METROLOTION
MUPIROCIN
NEOSPORIN G.U.
IRRIGANT
PHISOHEX
ROSADAN
SILVADENE
SULFAMYLON
TERSI FOAM
VELTIN
3
3
3
3
3
3
3
3
3
3
ZIANA
3
Dermatological Anti-inflammatory Agents
alclometasone
(Aclovate)
dipropionate
amcinonide
(Amcinonide)
APEXICON
betamethasone
(Del-beta)
dipropionate
betamethasone valerate
(Betamethasone Valerate)
betamethasone/‌propylene (Diprolene AF)
glyc
clobetasol propionate
(Temovate)
desonide
(Desowen)
desoximetasone
(Topicort)
diflorasone diacetate
(Psorcon)
fluocinolone acetonide
(Synalar)
fluocinolone/‌shower cap (Derma-smoothe-fs)
fluocinonide
(Fluocinonide)
fluticasone propionate
(Cutivate)
3
3
3
3
3
3
Age must be
<= 25
Age must be
<= 25
1
1
1
1
1
1
1
1
1
1
1
1
1
1
cream (g), lotion, oint. (g)
cream (g), oint. (g)
Page 69 of 126
D‌rug Name
halobetasol propionate
hydrocort/‌pramoxin/‌emol
/‌pram#1
hydrocortisone
ac/‌lidocaine
hydrocortisone acetate
hydrocortisone
acetate/‌aloe v
hydrocortisone
acetate/‌urea
hydrocortisone butyrate
hydrocortisone valerate
hydrocortisone
hydrocortisone/‌iodoquino
l
hydrocortisone/‌lidocaine/‌
aloe
hydrocortisone/‌pramoxin
e
mometasone furoate
prednicarbate
PROCTOCREAM-HC
REDERM
triamcinolone acetonide
betamethasone valerate
ELIDEL
PRAMOSONE E
ACLOVATE
ANALPRAM HC
ANAMANTLE HC
FORTE
ANAMANTLE HC
ANAMANTLE HC
ANUSOL-HC
APEXICON E
AQUAPHILIC W/‌TAC +
CARBAMIDE
Drug
Tier
(Ultravate)
(Analpram E)
1
1
(Hydrocortisone
Ac/‌lidocaine)
(Anusol-HC)
(Nuzon)
1
(Carmol HC)
1
(Hydrocortisone Butyrate)
(Hydrocortisone Valerate)
(Hytone)
(Hydrocortisone/‌iodoquinol)
1
1
1
1
(Peranex HC)
1
(Pramcort)
1
(Elocon)
(Dermatop)
1
1
1
1
1
2
2
2
2
3
3
3
(Triamcinolone Acetonide)
(Luxiq)
(Cutivate)
1
1
3
3
3
3
3
lotion, oint. (g), supp.rect
gel w/‌appl, kit: 2.5-3%(7g)
cream/‌appl
foam
lotion
cream/‌appl, kit: 0.5%-3%
kit: 2.5-3%(7g)
Page 70 of 126
D‌rug Name
AQUAPHILIC
W/‌TRIAMCINOLONE
BETAMETHASONE
DIPROPIONATE
BETAMETHASONE
VALERATE
CAPEX SHAMPOO
CARMOL HC
CLOBETASOL
PROPIONATE
CLOBEX
clocortolone pivalate
Drug
Tier
3
3
3
3
3
3
CLODERM (Eff 03/1/14
CORDRAN SP
CORDRAN
CORTENEMA
CORTIFOAM
CUTIVATE
DERMA-SMOOTHE-FS
DERMATOP
DESONATE
DESONIDE
DESOXIMETASONE
DIPROLENE AF
DIPROLENE
DIPROSONE
ELOCON
EPIFOAM
FIRSTHYDROCORTISONE
FLUOCINOLONE
ACETONIDE
FLUOCINONIDE
HALOG
HALONATE PAC
HALONATE
HYDROCORTISONE
ACETATE
3
2
0.1%
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Page 71 of 126
D‌rug Name
HYDROCORTISONE
KENALOG
LACTICARE-HC
LOCOID
LUXIQ
NOVACORT
NUCORT
OLUX-E
PANDEL
PRAMOSONE
PROCTOCORT
PROCTOCORT
PROCTOCREAM-HC
PROCTOFOAM-HC
PROTOPIC
RECTACORT-HC
RECTAGEL HC
SCALACORT
SYNALAR
clobetasol propionate
TOPICORT
TRIDERM
TRIDESILON
ULTRAVATE PAC
ULTRAVATE
fluocinonide
TEMOVATE (Eff 3/1/14
Tier Changed from 3 to 2)
VANOS (Eff 3/1/14 Tier
Changed from 3 to 2)
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
cream (g)
supp.rect
cream (g)
cream (g), solution
cream (g), foam, gel
(gram), lotion, oint. (g):
0.1%; shampoo, solution
3
3
3
3
3
2
VERDESO
WESTCORT
ZYPRAM
Dermatological Retinoids
adapalene
(Differin)
3
3
3
tretinoin
(Retin-A)
1
tretinoin/‌emollient
(Tretinoin/‌emollient)
1
1
Age must be
<= 25
Age must be
<= 25
cream (g): 0.025%; gel
(gram): 0.025%
cream (g): 0.05%
Page 72 of 126
D‌rug Name
Drug
Tier
tretinoin microspheres
(Retin-a Micro)
2
tretinoin
(Retin-A)
2
ATRALIN
3
DIFFERIN
3
EPIDUO
3
RETIN-A MICRO
3
RETIN-A
3
TARGRETIN
TAZORAC
3
3
TRETIN-X
3
TRETIN-X
3
TRETIN-X
3
TRETIN-X
Scabicides and Pediculicides
lindane
(Lindane)
malathion
(Ovide)
permethrin
(Elimite)
spinosad
(Natroba)
EURAX
NATROBA
OVIDE
SKLICE
3
1
1
1
2
3
3
3
3
Age must be
<= 25
Age must be
<= 25
Age must be
<= 25
Age must be
<= 25
Age must be
<= 25
Age must be
<= 25
Age must be
<= 25
Age must be
<= 25
Age must be
<= 25
Age must be
<= 25
cream (g): 0.05%, 0.1%;
gel (gram): 0.01%, 0.025%
combo. pkg: 0.025%,
0.05%
cream (g)
combo. pkg: 0.01%,
0.025%
combo. pkg: 0.1%
QL: 117 in
30 days
Devices
Devices
needles, insulin
disposable
(Needles, Insulin
Disposable)
2
Page 73 of 126
D‌rug Name
syring wndl,disp,insul,0.3ml
syring wndl,disp,insul,0.5ml
syringe &
needle,insulin,1 ml
CAPHOSOL
EPICERAM
MUGARD
PROMISEB
TETRIX
XEROFORM
PETROLATUM
DRESSING
(Syring Wndl,disp,insul,0.3ml)
(Syring Wndl,disp,insul,0.5ml)
(Syringe & Needle,insulin,1
Ml)
Drug
Tier
2
2
2
3
3
3
3
3
3
Diagnostic Agents
Diagnostic Agents
CERETEC
3
Enzyme Replacement/‌modifiers
Enzyme Replacement/‌modifiers
CREON
LOTRONEX
PANCREAZE
ZENPEP
CHENODAL
CYSTAGON
LINZESS
PERTZYE
SUCRAID
ULTRESA
VIOKACE
ADAGEN
ALDURAZYME
CEREZYME
CIMZIA
ELAPRASE
ELELYSO
KUVAN
MYOZYME
2
2
2
2
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
PA
PA
PA
PA
PA
PA
PA
syringekit
Page 74 of 126
D‌rug Name
NAGLAZYME
ORFADIN
PULMOZYME
VPRIV
ZAVESCA
Drug
Tier
4
4
4
4
4
PA
PA
PA
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Anti-infectives Agents
acetic acid
(Vosol)
acetic
(Vosol HC)
acid/‌hydrocortisone
bacitracin
(Bacitracin)
bacitracin/‌polymyxin b
(Polycin-b)
sulfate
ciprofloxacin hcl
(Ciloxan)
cresyl ace/‌ben
(Cresyl Ace/‌ben
alc/‌butanol/‌ipa
Alc/‌butanol/‌ipa)
erythromycin base
(Ilotycin)
gentamicin sulfate
(Garamycin)
levofloxacin
(Quixin)
neo/‌polymyx b
(Ak-trol)
sulf/‌dexameth
neomy
(Neo-polycin)
sulf/‌bacitra/‌polymyxin b
neomy sulf/‌bacitrac
(Triple Antibiotic HC)
zn/‌poly/‌hc
neomycin/‌polymyxin b
(Oticin HC)
sulf/‌hc
neomycin/‌polymyxn
b/‌gramicidin
ofloxacin
polymyxin b
sulf/‌trimethoprim
sulfacetamide/‌prednisolo
ne sp
TERAK
tobramycin
1
1
1
1
1
1
1
1
1
1
1
1
1
(Neosporin)
1
(Floxin)
(Polytrim)
1
1
(Sulfac)
(Sulfacetamide/‌prednisolone
Sp)
1
1
(Tobrex)
drops
drops susp: 3.5-10k-1, 3.510k-10; solution: 3.5-10k1
drops: 10%; oint. (g)
1
1
Page 75 of 126
D‌rug Name
tobramycin/‌dexamethaso
ne
trifluridine
BESIVANCE
BLEPHAMIDE S.O.P.
BLEPHAMIDE
CIPRODEX
ciprofloxacin hcl
COLY-MYCIN S
PRED-G
VIGAMOX
ZIRGAN
AZASITE
CETRAXAL
CILOXAN
CIPRO HC
CORTISPORIN
Drug
Tier
(Tobradex)
1
(Viroptic)
1
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
(Cetraxal)
(Sulfac)
CORTISPORIN
CORTISPORIN-TC
FLOXIN
GARAMYCIN
ILOTYCIN
MAXITROL
MOXEZA
NEO-POLYCIN
NEOSPORIN
OCUFLOX
OPTIMYD
OTICIN HC
POLYTRIM
TOBRADEX ST
TOBRADEX
TOBREX
TRIFLURIDINE
TRIPLE ANTIBIOTIC
VIROPTIC
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
droperette
drops: 10%
drops susp: 3.5-10k-1;
solution
drops susp: n/‌a
drops
Page 76 of 126
D‌rug Name
Drug
Tier
VOSOL HC
ZYLET
ZYMAXID
NATACYN
VOSOL
Eye, Ear, Nose, Throat Anti-inflammatory Agents
bromfenac sodium
(Bromfenac Sodium)
dexamethasone sod
(Ak-dex)
phosphate
diclofenac sodium
(Voltaren)
fluocinolone acetonide oil (Dermotic)
fluorometholone
(Fluorometholone)
flurbiprofen sodium
(Ocufen)
hc/‌pramox hcl/‌cl(HC/‌pramox HCl/‌clxylenol/‌water
xylenol/‌water)
hc/‌pramoxine
(Oticin HC)
hcl/‌chloroxylenol
ketorolac tromethamine (Acular)
prednisolone acetate
(Omnipred)
prednisolone sod
(Prednisol)
phosphate
ALREX
FLAREX
FML FORTE
FML S.O.P.
FML
LOTEMAX
MAXIDEX
NEVANAC
PRED MILD
ACULAR LS
ACULAR
ACUVAIL
ALOCRIL
BROMDAY
DECADRON
DERMOTIC
DEXASOL
3
3
3
4
4
PA
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
Page 77 of 126
D‌rug Name
DUREZOL
FLUOROMETHOLONE
ILEVRO
OCUFEN
OMNIPRED
PRED FORTE
PROLENSA
RESTASIS
VEXOL
Eye, Ear, Nose, Throat Drugs, Miscellaneous
apraclonidine hcl
(Iopidine)
atropine sulfate
(Isopto Atropine)
azelastine hcl
(Astelin)
carteolol hcl
(Carteolol HCl)
cromolyn sodium
(Cromolyn Sodium)
epinastine hcl
(Elestat)
homatropine hbr
(Isopto Homatropine)
naphazoline hcl
(Albalon)
phenylephrine hcl
(Mydfrin)
proparacaine hcl
(Ophthetic)
ASTEPRO
ISOPTO
HOMATROPINE
ISOPTO HYOSCINE
PATADAY
AKTEN
ALOMIDE
ASTELIN
BEPREVE
DYMISTA
ELESTAT
EMADINE
GELFILM
IOPIDINE
ISOPTO ATROPINE
ISOPTO
HOMATROPINE
LACRISERT
Drug
Tier
3
3
3
3
3
3
3
3
3
1
1
1
1
1
1
1
1
1
1
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
drops: 0.5%
drops: 2%
ST
drops: 5%
3
Page 78 of 126
D‌rug Name
LASTACAFT
MYDFRIN
OPTIVAR
PATANOL
TYZINE
CYSTARAN
tropicamide
(Mydral)
Drug
Tier
3
3
3
3
3
4
4
PA
drops: 1%
Gastrointestinal Agents
Antiulcer Agents And Acid Suppressants
cimetidine hcl
(Cimetidine HCl)
cimetidine
(Tagamet)
1
1
famotidine
(Pepcid)
1
misoprostol
omeprazole magnesium
omeprazole
omeprazole
(Cytotec)
(Omeprazole Magnesium)
(Omeprazole)
(Prilosec)
1
1
1
1
pantoprazole sodium
(Protonix)
1
PREVACID 24HR
ranitidine hcl
(Zantac)
1
1
sucralfate
ZEGERID OTC
lansoprazole
(Carafate)
(Prevacid)
1
1
2
nizatidine
omeprazole/‌sodium
bicarbonate
ACIPHEX
(Axid)
(Zegerid)
2
2
AXID
CARAFATE
CIMETIDINE
CYTOTEC
3
solution
tablet: 200mg, 300mg,
400mg, 800mg
oral susp, tablet: 20mg,
40mg
tablet dr
QL: 30 in 30 capsule dr: 10mg, 20mg,
days
40mg
QL: 30 in 30 tablet dr
days
capsule, syrup, tablet:
150mg, 300mg
ST, QL: 30
in 30 days
ST, QL: 30
in 30 days
ST, QL: 30
in 30 days
3
3
3
3
Page 79 of 126
D‌rug Name
DEXILANT
FAMOTIDINE
LANSOPRAZOLE
MISOPROSTOL HPMC
esomeprazole sodium
Drug
Tier
3
NEXIUM (Eff 3/1/14 Tier
Change from 3 to 2)
OMECLAMOX-PAK
OMEPRAZOLE
PEPCID RPD
PEPCID
PREVACID
PREVPAC
PRILOSEC
PRILOSEC
PROTONIX
RANITIDINE HCL
SUCRALFATE
TAGAMET
ZANTAC 25
ZANTAC
ZEGERID
Gastrointestinal Agents, Other
cromolyn sodium
(Gastrocrom)
dicyclomine hcl
(Bentyl)
diphenoxylate
(Lomotil)
hcl/‌atropine
GASTRINEX NF
glycopyrrolate
(Robinul)
ST, QL: 30
in 30 days
3
3
3
2 w/ ST ST, QL: 30
in 30 days
3
QL: 240 in
365 days
3
QL: 30 in 30
days
3
3
3
ST, QL: 30
in 30 days
3
3
ST, QL: 30
in 30 days
3
ST, QL: 30
in 30 days
3
ST, QL: 30
in 30 days
3
3
3
3
3
3
ST, QL: 30
in 30 days
20mg, 40mg
capsule dr
suspdr pkt
tablet: 400mg, 800mg
syrup, tablet
1
1
1
1
1
tablet
Page 80 of 126
D‌rug Name
Drug
Tier
hyoscyamine sulfate
(Symax-sl)
1
isopropamide/‌prochlorpe
razine
lactulose
loperamide hcl
methscopolamine
bromide
METOCLOPRAMIDE
HCL INTENSOL
metoclopramide hcl
paregoric
CUVPOSA
KRISTALOSE
opium tincture
PYLERA
ursodiol
ACTIGALL
AMITIZA
ANASPAZ
BENTYL
BUPHENYL
CANTIL
FULYZAQ
GASTROCROM
HELIDAC
LEVSIN
LEVSIN-SL
LOMOTIL
LOPERAMIDE
METOCLOPRAMIDE
HCL
METOZOLV ODT
(Isopropamide/‌prochlorperaz
ine)
(Lactulose)
(Loperamide HCl)
(Pamine)
1
drops: 0.125mg/‌ml; elixir,
tab rapdis: 0.125mg; tab
subl, tablet: 0.125mg
1
1
1
capsule, liquid
1
(Reglan)
(Paregoric)
(Opium Tincture)
(Actigall)
MOTOFEN
NULEV
PAMINE FORTE
1
1
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
solution, tablet
capsule, tablet
PA
QL: 120 in
30 days
3
3
3
Page 81 of 126
D‌rug Name
PAMINE
REGLAN
RELISTOR
ROBINUL FORTE
ROBINUL
SYMAX
SYMAX-SL
URSO FORTE
URSO
URSODIOL
CARBAGLU
Laxatives
peg 3350/‌na
(Golytely)
sulf,bicarb,cl/‌kcl
polyethylene glycol 3350 (Miralax)
sodium
(Nulytely with Flavor Packs)
chloride/‌nahco3/‌kcl/‌peg
COLYTE with FLAVOR
PACKETS
GOLYTELY
HALFLYTELYBISACODYL
MOVIPREP
SUPREP
GOLYTELY
NULYTELY with
FLAVOR PACKS
OSMOPREP
SUCLEAR
Phosphate Binders
calcium acetate
(Phoslo)
sodium polystyrene
(Sodium Polystyrene
sulfonate
Sulfonate)
PHOSLYRA
RENVELA
sodium polystyrene
(Sodium Polystyrene
sulfonate
Sulfonate)
FOSRENOL
Drug
Tier
3
3
3
3
3
3
3
3
3
3
4
PA
tablet
PA
1
1
1
2
2
2
2
2
3
3
powd pack
soln recon
3
3
1
1
oral susp
2
2
2
enema
3
Page 82 of 126
D‌rug Name
PHOSLO
RENAGEL
Drug
Tier
3
3
Genitourinary Agents
Antispasmodics, Urinary
flavoxate hcl
(Urispas)
oxybutynin chloride
(Ditropan)
tolterodine tartrate
(Detrol)
trospium chloride
(Sanctura)
DETROL LA
ENABLEX
VESICARE
DETROL
DITROPAN XL
GELNIQUE
GELNIQUE
MYRBETRIQ
OXYBUTYNIN
CHLORIDE
OXYTROL
SANCTURA XR
SANCTURA
TOVIAZ
1
1
2
1
2
2
2
3
3
3
3
3
3
3
3
3
3
2mg, 4mg
gel md pmp
gel packet
ST
QL: 30 in 30
days
Page 83 of 126
D‌rug Name
Drug
Tier
Heavy Metal Antagonists
Heavy Metal Antagonists
CHEMET
CUPRIMINE
DEPEN
SYPRINE
EXJADE
FERRIPROX
2
2
3
3
4
4
PA
PA
Hormonal Agents, Stimulant/‌replacement/‌modifying
Androgens
danazol
(Danocrine)
estrogen,ester/‌me(Estratest)
testosterone
oxandrolone
(Oxandrin)
testosterone cypionate
(Depo-testosterone)
testosterone enanthate
(Delatestryl)
fluoxymesterone
(Fluoxymesterone)
ANADROL-50
ANDRODERM
ANDROGEL
ANDROID
AXIRON
DANAZOL
DEPOTESTOSTERONE
FORTESTA
METHITEST
OXANDRIN
OXANDROLONE
STRIANT
TESTIM
TESTOSTERONE
CYPIONATE
TESTOSTERONE
ENANTHATE
TESTOSTERONE
TESTRED
Estrogens and Antiestrogens
1
1
1
1
1
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Page 84 of 126
D‌rug Name
estradiol
estradiol/‌norethindrone
acet
estropipate
norethind ac/‌ethinyl
estradiol
ALORA
CLIMARA PRO
DIVIGEL
ESTRACE
ESTRACE
ESTROGEL
raloxifene hcl
MENOSTAR
PREFEST
PREMARIN
PREMARIN
PREMPHASE
PREMPRO
VAGIFEM
ACTIVELLA
CENESTIN
CLIMARA
COMBIPATCH
ELESTRIN
ENJUVIA
ESTRADIOL
MICRONIZED
ESTRASORB
ESTRING
ESTRIOL
MICRONIZED
ESTRIOL
ESTRONE SULFATE
PIPERAZINE
ESTRONE
EVAMIST
Drug
Tier
(Estrace)
(Activella)
1
1
(Ogen)
(Femhrt)
1
1
EVISTA
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
GF
tablet
cream/‌appl
60mg
GF
tablet
cream/‌appl
GF
GF
3
3
3
3
QL: 16.2 in
30 days
Page 85 of 126
D‌rug Name
FEMHRT
FEMRING
MENEST
MINIVELLE
OSPHENA
VIVELLE-DOT
Glucocorticoids/‌mineralocorticoids
cortisone acetate
(Cortisone Acetate)
DEXAMETHASONE
INTENSOL
dexamethasone
(Dexamethasone)
fludrocortisone acetate
(Fludrocortisone Acetate)
hydrocortisone
(Cortef)
methylprednisolone
(Medrol)
prednisolone sod
(Orapred)
phosphate
prednisolone
(Prednisolone)
PREDNISONE
INTENSOL
prednisone
(Prednisone)
DEXPAK
ARISTOCORT
BETAMETHASONE
ACETATE
BETAMETHASONE
SODIUM PHOSPHATE
BETAMETHASONE
BUDESONIDE
MICRONIZED
CELESTONE
CORTEF
CORTISONE ACETATE
DEXAMETHASONE
SODIUM PHOSPHATE
DEXAMETHASONE
FLO-PRED
FLUDROCORTISONE
ACETATE
Drug
Tier
3
3
3
3
3
3
GF
1
1
1
1
1
1
1
1
1
1
2
3
3
3
3
3
3
3
3
3
solution
3
3
3
Page 86 of 126
D‌rug Name
Drug
Tier
FLUNISOLIDE
FLUTICASONE
PROPIONATE
MEDROL
METHYLPREDNISOLO
NE AC MICRO
METHYLPREDNISOLO
NE SODIUM SUCC
MILLIPRED DP
MILLIPRED
MILLIPRED
MOMETASONE
FUROATE
ORAPRED ODT
ORAPRED
PREDNISOLONE
ACETATE MICRONIZE
PREDNISOLONE
SODIUM PHOSPHATE
PREDNISOLONE
PREDNISONE
RAYOS
TRIAMCINOLONE
ACETONIDE
TRIAMCINOLONE
VERIPRED 20
Pituitary
desmopressin acetate
(DDAVP)
3
3
DDAVP
DDAVP
DDAVP
STIMATE
CHORIONIC
GONADOTROPIN
desmopressin acetate
INCRELEX
octreotide acetate
3
3
3
3
4
PA
4
4
4
PA
PA
PA
(Desmopressin Acetate)
(Sandostatin)
3
3
3
3
3
3
3
solution
tablet
3
3
3
3
3
3
3
3
ST
3
3
1
solution, spray/‌pump,
tablet
solution, tablet
spray/‌pump
ampul
PA
vial
Page 87 of 126
D‌rug Name
Drug
Tier
SANDOSTATIN
4
SOMATULINE DEPOT
4
SOMATULINE DEPOT
SOMAVERT
Progestins
medroxyprogesterone
acet
medroxyprogesterone
acetate
norethindrone acetate
progesterone,micronized
AYGESTIN
CRINONE
DEPO-PROVERA
DEPO-SUBQ
PROVERA 104
ENDOMETRIN
FIRSTPROGESTERONE VGS
100
200
25
400
50
MEDROXYPROGESTE
RONE ACETATE
NORETHINDRONE
ACETATE
PROCHIEVE
4
4
(Medroxyprogesterone Acet)
1
(Provera)
1
(Aygestin)
(Prometrium)
1
1
3
3
3
3
3
3
PA
PA
PA
ampul: 100mcg/‌ml,
500mcg/‌ml; vial
disp syrin: 90mg/‌0.3ml,
120mg/‌0.5
disp syrin: 60mg/‌0.2ml
GF, PA
GF, PA
3
3
3
3
3
3
3
GF, PA
Page 88 of 126
D‌rug Name
Drug
Tier
PROGESTERONE
MICRONIZED
PROGESTERONE
PROGESTERONE
PROMETRIUM
PROVERA
Thyroid and Antithyroid Agents
LEVOTHROID
levothyroxine sodium
(Levoxyl)
LEVOTHYROXINE
SODIUM
LEVOXYL
liothyronine sodium
(Cytomel)
methimazole
(Tapazole)
METHIMAZOLE
potassium iodide/‌iodine (Potassium Iodide/‌iodine)
propylthiouracil
(Propylthiouracil)
thyroid,pork
(Thyroid,pork)
3
UNITHROID
ARMOUR THYROID
LIOTHYRONINE
SODIUM
LIOTHYRONINE
SODIUM
potassium iodide
potassium iodide/‌iodine
SYNTHROID
thyroid,pork
1
2
2
powder: 100%
2
powder: 100%
(Potassium Iodide)
(Potassium Iodide/‌iodine)
(Thyroid,pork)
THYROID
TIROSINT
CYTOMEL
TAPAZOLE
THYROLAR-1/‌2
3
3
3
3
1
1
1
1
1
1
1
1
1
1
2
2
2
2
powder: 100%
powder: 100%
tablet, vial: 200mcg
tablet
solution: 5%
tablet: 16.25mg, 32.5mg,
65mg, 97.5mg, 130mg,
195mg, 260mg, 325mg
solution: 5%
tablet: 16.25mg, 32.5mg,
48.75mg, 65mg, 97.5mg,
130mg, 195mg, 260mg,
325mg
2
2
3
3
3
Page 89 of 126
D‌rug Name
THYROLAR-1/‌4
THYROLAR-1
THYROLAR-2
THYROLAR-3
Drug
Tier
3
3
3
3
Immunological Agents
Immunological Agents
azathioprine
(Imuran)
cyclosporine
(Sandimmune)
cyclosporine, modified
(Neoral)
leflunomide
(Arava)
mycophenolate mofetil
(Cellcept)
tacrolimus
(Hecoria)
ARAVA
sirolimus
RAPAMUNE
AZASAN
CELLCEPT
HECORIA
IMURAN
mycophenolate sodium
MYFORTIC (Eff 3/1/14 Tier
Changed from 3 to 2)
NEORAL
PROGRAF
RIDAURA
SANDIMMUNE
ARCALYST
ATGAM
AUBAGIO
CELLCEPT
ENBREL
HUMIRA
ILARIS
KINERET
NULOJIX
ORENCIA
ORENCIA
PRIVIGEN
TYSABRI
ZORTRESS
1
1
1
1
1
1
2
2
3
3
3
3
2
3
3
3
3
4
4
4
4
4
4
4
4
4
4
4
4
4
4
capsule, solution
ST
capsule, susp recon, tablet
180mg, 360mg
capsule
capsule, solution
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA NSO
PA NSO
PA
PA
PA
vial
disp syrin
vial
Page 90 of 126
D‌rug Name
Vaccines
TYPHIM VI
Drug
Tier
2
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease Agents
balsalazide disodium
(Colazal)
mesalamine w/‌cleansing (Rowasa)
wipes
APRISO
ASACOL HD
ASACOL
budesonide
(Entocort EC)
CANASA
DELZICOL
DIPENTUM
PENTASA
5-AMINOSALICYLIC
ACID
COLAZAL
ENTOCORT EC
LIALDA
SFROWASA
1
1
2
2
2
2
2
2
2
2
3
3
3
3
3
Irrigating Solutions
Irrigating Solutions
mannitol/‌sorbitol solution (Mannitol/‌sorbitol Solution)
TIS-U-SOL
3
4
PA
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
alendronate sodium
(Fosamax)
calcitonin,salmon,syntheti (Miacalcin)
c
calcitriol
(Rocaltrol)
etidronate disodium
(Didronel)
FORTICAL
ibandronate sodium
(Boniva)
ATELVIA
BONIVA
doxercalciferol
HECTOROL
ACTONEL
1
1
1
1
1
1
2
2
2
3
capsule, solution
ST
PA
disp syrin
0.5mcg, 1mcg, 2.5mcg
ST
Page 91 of 126
D‌rug Name
BINOSTO
BONIVA
DIDRONEL
FOSAMAX PLUS D
FOSAMAX
MIACALCIN
ROCALTROL
SKELID
ZEMPLAR
FORTEO
pamidronate disodium
PROLIA
ZOMETA
(Aredia)
Drug
Tier
3
3
3
3
3
3
3
3
3
4
4
4
4
ST
ST
tablet
ST
ST
spray/‌pump
capsule
PA
PA
PA
PA
vial: 60mg/‌10ml
vial
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
allopurinol
(Zyloprim)
bethanechol chloride
(Urecholine)
buspirone hcl
(Buspar)
colchicine
(Colchicine)
colchicine/‌probenecid
(Colchicine/‌probenecid)
ergoloid mesylates
(Ergoloid Mesylates)
finasteride
(Proscar)
guanidine hcl
(Guanidine HCl)
hydroxyzine hcl
(Hydroxyzine HCl)
hydroxyzine pamoate
(Vistaril)
leucovorin calcium
(Leucovorin Calcium)
levocarnitine (with sugar) (Carnitor)
levocarnitine
(Carnitor)
meprobamate
(Miltown)
methylergonovine
(Methergine)
maleate
neostigmine methylsulfate (Neostigmine Methylsulfate)
probenecid
(Probenecid)
pyridostigmine bromide (Mestinon)
chloral hydrate
(Chloral Hydrate)
GLUCAGEN
GLUCAGON
EMERGENCY KIT
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
syrup, tablet
tablet
tablet
tablet
vial: 1:1000
Page 92 of 126
D‌rug Name
Drug
Tier
MESTINON
MYTELASE
RECTIV
ULESFIA
ACETIC ACID
ALLOPURINOL
AVODART
2
2
2
2
3
3
3
AZATHIOPRINE
BETHANECHOL
CHLORIDE
CAPSULE #1
CARNITOR
CARNITOR
COLCHICINE
COLCRYS
CYCLOSPORINE
CYSTADANE
DISULFIRAM
ELMIRON
FOOD COLOR GREEN
JALYN
LEUCOVORIN
CALCIUM
LEVOCARNITINE
LITHOSTAT
MESNEX
METHOCEL E 4 M
NEOSTIGMINE
BROMIDE
NICOTINE
POLACRILEX
PREGNENOLONE
PROSCAR
PROSTIGMIN
PYRIDOSTIGMINE
BROMIDE
RADIAPLEXRX
3
3
QL: 30 in 30
days
3
3
3
3
3
3
3
3
3
3
3
3
solution
tablet, vial
powder: n/‌a
3
3
3
3
3
tablet
3
3
3
3
3
GM
3
Page 93 of 126
D‌rug Name
SYNAREL
TACROLIMUS
TACROLIMUS
THIOLA
ULORIC
URECHOLINE
VISTARIL
XCLAIR
ZYLOPRIM
ACTIMMUNE
amifostine crystalline
ammonium chloride
AVONEX
ADMINISTRATION
PACK
AVONEX
(Ethyol)
(Ammonium Chloride)
Drug
Tier
3
3
3
3
3
3
3
3
3
4
4
4
4
4
BETASERON
4
BOTOX
COPAXONE
4
4
ETHYOL
EXTAVIA
4
4
GILENYA
REBIF REBIDOSE
4
4
REBIF REBIDOSE
4
REBIF REBIDOSE
REBIF
4
4
REBIF
4
REBIF
REMICADE
SENSIPAR
4
4
4
powder: 100%
powder: 100%
ST
PA
PA
PA
PA, QL: 1 in
30 days
PA, QL: 1 in
30 days
PA, QL: 15
in 30 days
PA
PA, QL: 4 in
30 days
PA, QL: 15
in 30 days
PA
PA, QL: 4 in
30 days
PA, QL: 6 in
30 days
PA
PA, QL: 4 in
30 days
PA, QL: 6 in
30 days
PA
PA
pen injctr: 22mcg/‌.5ml
pen injctr: 44mcg/‌.5ml
pen injctr: 8.8-22(6)
disp syrin: 22mcg/‌.5ml
disp syrin: 44mcg/‌.5ml
disp syrin: 8.8-22(6)
Page 94 of 126
D‌rug Name
SIGNIFOR
SIMPONI
SIMULECT
STELARA
TECFIDERA
THALOMID
VORAXAZE
XELJANZ
Drug
Tier
4
4
4
4
4
4
4
4
PA
PA
PA
PA
PA
PA
PA
Opthalmic Agents
Antiglaucoma Agents
acetazolamide
(Acetazolamide)
betaxolol hcl
(Betaxolol HCl)
brimonidine tartrate
(Alphagan P)
dorzolamide hcl
(Trusopt)
dorzolamide hcl/‌timolol (Cosopt)
maleat
latanoprost
(Xalatan)
levobunolol hcl
(Betagan)
methazolamide
(Neptazane)
metipranolol
(Optipranolol)
pilocarpine hcl
(Isopto Carpine)
timolol maleate
(Timoptic)
ISOPTO CARPINE
PHOSPHOLINE
IODIDE
PILOPINE HS
TRAVATAN Z
travoprost
(Travatan)
(benzalkonium)
ACETAZOLAMIDE
ALPHAGAN P
AZOPT
BETAGAN
BETIMOL
BETOPTIC S
COMBIGAN
COSOPT PF
COSOPT
1
1
1
1
1
1
1
1
1
1
1
2
2
drops: 8%
2
2
2
3
3
3
3
3
3
3
3
3
Page 95 of 126
D‌rug Name
DIAMOX SEQUELS
ISOPTO CARPINE
ISTALOL
LUMIGAN
NEPTAZANE
OPTIPRANOLOL
PILOCARPINE HCL
RESCULA
SIMBRINZA
TIMOPTIC
TIMOPTIC-XE
TRUSOPT
XALATAN
ZIOPTAN
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
drops: 1%, 2%, 4%
ST
Replacement Preparations
Replacement Preparations
citric acid/‌sodium citrate (Bicitra)
phosphorus #1
(K-phos Neutral)
pot chloride/‌pot
(Pot Chloride/‌pot Bicarb/‌cit
bicarb/‌cit ac
Ac)
potassium bicarbonate/‌cit (Potassium Bicarbonate/‌cit
ac
Ac)
potassium chloride
(K-dur)
potassium citrate
potassium citrate/‌citric
acid
potassium gluconate
sod/‌pot/‌k cit/‌sod cit/‌cit
acid
sodium chloride for
inhalation
EFFER-K
HYPER-SAL
K-LOR
K-PHOS NO.2
1
1
1
1
1
(Urocit-K) (Eff 3/1/14 Tier
Change from 1 to 2)
(Polycitra-k)
2
(Potassium Gluconate)
(Polycitra-lc)
1
1
(Hyper-sal)
1
capsule er, liquid, packet,
tab er prt, tablet er, tablet
sa
1
2
2
2
2
Page 96 of 126
D‌rug Name
K-PHOS ORIGINAL
K-TAB
NEBUSAL
ORACIT
QUIC-K
K-PHOS NEUTRAL
POTASSIUM CITRATE
UROCIT-K
ISOLYTE S
magnesium sulfate
PLASMA-LYTE 148
PLASMA-LYTE 56
potassium chloride0.45% nacl
sodium chloride 3%
(Magnesium Sulfate)
(Potassium Chloride-0.45%
NaCl)
(Sodium Chloride 3%)
Drug
Tier
2
2
2
2
2
3
3
3
4
4
4
4
4
4
PA
PA
PA
vial
PA
PA
Respiratory Tract Agents
Anti-inflammatories, Inhaled Corticosteroids
flunisolide
(Nasarel)
(Flonase)
triamcinolone acetonide (Nasacort Aq)
ADVAIR DISKUS
ADVAIR HFA
budesonide
(Pulmicort)
DULERA
FLOVENT DISKUS
FLOVENT HFA
NASONEX
PULMICORT
FLEXHALER
QVAR
SYMBICORT
ALVESCO
ASMANEX
BECONASE AQ
BREO ELLIPTA
FLONASE
NASACORT AQ
OMNARIS
1
1
1
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
ST
ST
ST
ST
Page 97 of 126
D‌rug Name
Drug
Tier
PULMICORT
QNASL
RHINOCORT AQUA
VERAMYST
ZETONNA
Antileukotrienes
montelukast sodium
(Singulair)
zafirlukast
(Accolate)
SINGULAIR
ACCOLATE
SINGULAIR
ZYFLO CR
ZYFLO
Bronchodilators
albuterol sulfate
(Accuneb)
3
3
3
3
3
albuterol
aminophylline
ipratropium bromide
ipratropium/‌albuterol
sulfate
metaproterenol sulfate
terbutaline sulfate
theophylline anhydrous
(Albuterol)
(Aminophylline)
(Atrovent)
(Duoneb)
1
1
1
1
(Metaproterenol Sulfate)
(Brethine)
(Theochron)
1
1
1
ATROVENT HFA
COMBIVENT
RESPIMAT
COMBIVENT
FORADIL
levalbuterol hcl
(Xopenex)
MAXAIR AUTOHALER
PROAIR HFA
SEREVENT DISKUS
SPIRIVA
THEO-24
1
1
2
3
3
3
3
ST
ST
ST
ST
ST
ST
gran pack
ST
tab chew, tablet
1
solution, syrup, tab er 12h,
tablet, vial-neb:
0.63mg/‌3ml, 1.25mg/‌3ml,
2.5mg/‌3ml
liquid
tablet
elixir: 80mg/‌15ml; tab er
12h, tablet er
2
2
2
2
2
2
2
2
2
2
ST
Page 98 of 126
D‌rug Name
Drug
Tier
VENTOLIN HFA
VENTOLIN
ACCUNEB
ALBUTEROL
SULFATE
AMINOPHYLLINE
ARCAPTA NEOHALER
ATROVENT
BROVANA
DUONEB
LUFYLLIN
PERFOROMIST
PROVENTIL HFA
TUDORZA PRESSAIR
VOSPIRE ER
XOPENEX HFA
XOPENEX
aminophylline
(Aminophylline)
Respiratory Tract Agents, Other
cromolyn sodium
(Intal)
guaifenesin/‌dyphylline
(Difil-g)
2
2
3
3
guaifenesin/‌theophylline
guaifenesin/‌dyphylline
DALIRESP
IPRATROPIUM
BROMIDE
LUFYLLIN-GG
METHYLPHENIDATE
HCL
THEOPHYLLINE
ANHYDROUS
acetylcysteine
KALYDECO
PROLASTIN C
PROLASTIN
1
2
3
3
(Guaifenesin/‌theophylline)
(Difil-g)
3
3
3
3
3
3
3
3
3
3
3
3
4
ST
ST
PA
1
1
vial
elixir, tablet: 200-200mg,
300-200mg
liquid: 100-150
tablet: 200-200mg
ST
3
3
3
(Acetadote)
4
4
4
4
vial: 100mg/‌ml
PA
PA
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
Page 99 of 126
D‌rug Name
baclofen
chlorzoxazone
chlorzoxazone/‌acetamino
phen
cyclobenzaprine hcl
dantrolene sodium
methocarbamol
orphenadrine citrate
orphenadrine/‌aspirin/‌caff
eine
tizanidine hcl
carisoprodol
carisoprodol/‌aspirin
codeine/‌carisoprodol/‌aspi
rin
metaxalone
AMRIX
BACLOFEN
CARISOPRODOL
CYCLOBENZAPRINE
HCL
DANTRIUM
DANTROLENE
SODIUM
FEXMID
FLEXERIL
LORZONE
METHOCARBAMOL
ORPHENADRINE
CITRATE
ROBAXIN-750
ROBAXIN
SKELAXIN
SOMA
TIZANIDINE HCL
ZANAFLEX
Drug
Tier
(Baclofen)
(Parafon Forte DSC)
(Chlorzoxazone/‌acetaminoph
en)
(Fexmid)
(Dantrium)
(Robaxin)
(Norflex)
(Norgesic Forte)
1
1
1
(Zanaflex)
(Soma)
(Carisoprodol/‌aspirin)
(Codeine/‌carisoprodol/‌aspiri
n)
(Skelaxin)
1
2
2
2
1
1
1
1
1
2
3
3
3
3
capsule
tablet er
ST
3
3
3
3
3
3
3
3
3
3
3
3
3
capsule
ST
tablet
Sleep Disorder Agents
Sleep Disorder Agents
Page 100 of 126
D‌rug Name
zaleplon
zolpidem tartrate
zolpidem tartrate
modafinil
(Sonata)
(Ambien CR)
(Ambien)
(Provigil)
Drug
Tier
1
1
1
2
AMBIEN CR
AMBIEN
BUSPIRONE HCL
BUTISOL SODIUM
EDLUAR
INTERMEZZO
3
3
3
3
3
3
LUNESTA
NUVIGIL
3
3
PROVIGIL
3
ROZEREM
SECONAL SODIUM
SONATA
ZOLPIMIST
XYREM
3
3
3
3
4
ST
ST
tab mphase
tablet
PA, QL: 60
in 30 days
ST
ST
QL: 30 in 30
days
ST
PA, QL: 30
in 30 days
PA, QL: 60
in 30 days
ST
ST
PA
Sympatholytic Adrenergic Blocking Agents
Alpha-Adrenergic Blocking Agents
alfuzosin hcl
(Uroxatral)
tamsulosin hcl
(Flomax)
terazosin hcl
(Hytrin)
ERGOLOID
MESYLATES
FLOMAX
RAPAFLO
UROXATRAL
1
1
1
3
3
3
QL: 30 in 30
days
3
Vasodilating Agents
Vasodilating Agents
phenazopyridine hcl
(Pyridium)
yohimbine hcl
(Yocon)
1
2
tablet: 5.4mg
Page 101 of 126
D‌rug Name
Drug
Tier
CAVERJECT
3
CIALIS
3
EDEX
3
LEVITRA
3
MUSE
3
STAXYN
3
VIAGRA
3
ADCIRCA
LETAIRIS
REMODULIN
REVATIO
sildenafil citrate
TRACLEER
TYVASO
VENTAVIS
4
4
4
4
4
4
4
4
(Revatio)
ST, QL: 6 in
30 days
QL: 8 in 30
days
ST, QL: 6 in
30 days
QL: 8 in 30
days
QL: 6 in 30
days
QL: 8 in 30
days
QL: 8 in 30
days
PA
PA
PA
PA
PA
LA, PA
PA
PA
vial: 2.5mg/‌ml
Vitamins and Minerals
Vitamins and Minerals
iron &iron asp
(Iron &iron Asp
gly/‌fa/‌mv,min38
Gly/‌fa/‌mv,min38)
ACTIVE FE
CORVITE 150
CORVITE FE
FUSION PLUS
folic acid
(Folic Acid)
2
3
3
3
3
5
tablet
Page 102 of 126
INDEX
5-AMINOSALICYLIC ACID
........................................... 81
8-MOP .................................. 58
aa/‌antipyrn/‌bcaine/‌polico#1/‌al8
abacavir sulfate..................... 36
ABILIFY............................... 35
ABILIFY DISCMELT.......... 35
ABREVA .............................. 29
ABSORICA .......................... 58
ABSTRAL .............................. 2
ACANYA ............................. 61
acarbose................................ 22
ACCOLATE ......................... 88
ACCUHIST .......................... 28
ACCUHIST DM ................... 53
ACCUHIST PDX ................. 53
ACCUNEB ........................... 88
ACCUPRIL........................... 41
ACCURETIC........................ 41
acebutolol hcl........................ 42
ACEBUTOLOL HCL........... 42
ACEON................................. 41
acetaminophen with codeine... 1
acetaminophen/‌phenyltolx cit . 1
acetazolamide ....................... 85
ACETAZOLAMIDE ............ 85
acetic acid ............................. 67
ACETIC ACID ..................... 83
acetic acid/‌hydrocortisone.... 67
acetylcysteine ........................ 89
ACIPHEX ............................. 71
ACLOVATE ......................... 63
ACTIGALL........................... 73
ACTIMMUNE...................... 84
ACTIQ .................................... 3
ACTIVE FE .......................... 92
ACTIVELLA ........................ 76
ACTONEL............................ 82
ACTOPLUS MET ................ 24
ACTOPLUS MET XR.......... 24
ACTOS ................................. 24
ACULAR .............................. 69
ACULAR LS ........................ 69
ACUVAIL............................. 69
acyclovir.......................... 37, 58
ACYCLOVIR ....................... 38
acyclovir sodium ................... 38
ACZONE .............................. 58
ADAGEN.............................. 67
ADALAT CC........................ 44
adapalene.............................. 65
ADCIRCA ............................ 91
ADDERALL ......................... 48
ADDERALL XR .................. 48
ADOXA ................................ 14
ADOXA CK.......................... 14
ADOXA PAK ....................... 14
ADOXA TT .......................... 14
ADVAIR DISKUS ............... 87
ADVAIR HFA ...................... 87
ADVICOR ............................ 46
AFINITOR............................ 16
AFINITOR DISPERZ........... 16
AGGRENOX ........................ 39
AGRYLIN............................. 39
AKNE-MYCIN..................... 61
AKTEN ................................. 70
ALA-HIST AC...................... 53
ALAHIST DHC .................... 53
ALA-HIST DM..................... 53
ALAHIST LQ ....................... 28
ALA-TET.............................. 14
ALBENZA............................ 33
albuterol................................ 88
albuterol sulfate .................... 88
ALBUTEROL SULFATE .... 88
alclometasone dipropionate.. 62
ALCORTIN A ...................... 58
ALDACTAZIDE .................. 47
ALDACTONE ...................... 47
ALDARA.............................. 58
ALDEX GS........................... 53
ALDEX GS DM ................... 53
ALDURAZYME................... 67
alendronate sodium............... 82
alfuzosin hcl .......................... 91
ALINIA................................. 33
ALKERAN ........................... 15
ALLEGRA-D 12 HOUR 26, 28
ALLEGRA-D 24 HOUR ...... 28
ALLERX 30.......................... 28
ALLERX DF......................... 28
ALLERX DF 30.................... 28
ALLERX PE ......................... 28
ALLFEN CD......................... 53
ALLFEN CDX...................... 53
ALLFEN DM........................ 53
allopurinol ............................ 82
ALLOPURINOL................... 83
ALOCRIL ............................. 69
ALODOX.............................. 14
ALOMIDE ............................ 70
ALORA................................. 76
ALOXI .................................. 33
ALPHAGAN P ..................... 85
alprazolam .............................. 9
ALPRAZOLAM ..................... 9
ALPRAZOLAM INTENSOL. 8
ALREX ................................. 69
ALSUMA.............................. 30
ALTABAX ........................... 61
ALTACE............................... 41
ALTOPREV.......................... 46
aluminum chloride ................ 56
ALUVEA .............................. 58
ALVESCO ............................ 87
amantadine hcl...................... 34
AMANTADINE HCL .......... 34
AMARYL ............................. 24
AMBIEN............................... 90
AMBIEN CR ........................ 90
AMBIFED CD ...................... 53
AMBIFED CDX ................... 53
I-1
Formulary ID: 82112.000, Version: 1
AMBIFED DM ..................... 53
AMBIFED-G CD.................. 53
AMBIFED-G CDX............... 53
amcinonide............................ 62
AMERGE.............................. 30
AMETHYST......................... 49
AMEVIVE ............................ 60
amifostine crystalline ............ 84
amikacin sulfate .................... 10
amiloride hcl ......................... 45
AMILORIDE HCL ............... 45
amiloride/‌hydrochlorothiazide
........................................... 45
aminocaproic acid ................ 39
aminophylline.................. 88, 89
AMINOPHYLLINE ............. 88
amiodarone hcl ..................... 41
AMIODARONE HCL .......... 42
AMITIZA.............................. 73
amitrip hcl/‌chlordiazepoxide 20
amitriptyline hcl .................... 20
AMITRIPTYLINE HCL....... 21
AMLODIPINE BESILATE.. 44
amlodipine besylate .............. 44
amlodipine besylate/‌benazepril
........................................... 44
amlodipine/‌atorvastatin ........ 45
ammonium chloride .............. 84
ammonium lactate................. 56
amoxapine ............................. 20
amoxicillin............................. 12
AMOXICILLIN
TRIHYDRATE ................. 12
amoxicillin/‌potassium clav.... 12
AMOXIL............................... 12
amphotericin b ...................... 26
ampicillin sodium/‌sulbactam na
........................................... 13
ampicillin trihydrate ............. 12
AMPYRA ............................. 49
AMRIX ................................. 90
AMTURNIDE....................... 47
ANABAR................................ 3
ANACAINE.......................... 58
ANADROL-50...................... 75
ANAFRANIL ....................... 21
anagrelide hcl ....................... 39
ANALPRAM HC ................. 63
ANAMANTLE HC............... 63
ANAMANTLE HC FORTE . 63
ANAPROX ............................. 6
ANAPROX DS ....................... 6
ANASPAZ ............................ 73
anastrozole............................ 14
ANASTROZOLE ................. 15
ANCOBON........................... 25
ANDRODERM..................... 75
ANDROGEL......................... 75
ANDROID ............................ 75
ANGELIQ............................. 50
ANTABUSE ........................... 8
ANTARA.............................. 46
ANTHRALIN ....................... 58
antipyrine/‌benzocaine/‌glycerin8
ANTIVERT........................... 32
ANUSOL-HC ....................... 63
ANZEMET ........................... 32
APEXICON .......................... 62
APEXICON E....................... 63
APHTHASOL....................... 56
APIDRA................................ 23
APIDRA SOLOSTAR .......... 23
APLENZIN ........................... 21
APOKYN.............................. 35
apraclonidine hcl .................. 70
APRISO ................................ 81
APTIVUS.............................. 36
AQUAPHILIC W/‌TAC +
CARBAMIDE .................. 63
AQUAPHILIC
W/‌TRIAMCINOLONE .... 63
ARALEN PHOSPHATE ...... 33
ARANESP ............................ 38
ARAVA ................................ 80
ARCALYST ......................... 81
ARCAPTA NEOHALER ..... 88
ARICEPT.............................. 19
ARICEPT ODT..................... 19
ARIMIDEX........................... 15
ARISTOCORT ..................... 77
ARIXTRA............................. 38
ARMOUR THYROID .......... 80
AROMASIN ......................... 15
ARTHROTEC 50.................... 6
ARTHROTEC 75.................... 6
ARZERRA............................ 16
ASACOL .............................. 81
ASACOL HD........................ 81
ASMANEX........................... 87
aspirin ..................................... 5
ASTELIN.............................. 70
ASTEPRO............................. 70
ATACAND ........................... 40
ATACAND HCT .................. 40
ATELVIA ............................. 82
atenolol ................................. 42
ATENOLOL ......................... 43
atenolol/‌chlorthalidone......... 42
ATGAM................................ 81
ATIVAN ................................. 9
atorvastatin calcium.............. 45
atovaquone/‌proguanil hcl ..... 33
ATRALIN ............................. 65
ATRIPLA.............................. 36
atropine sulfate ............... 17, 70
ATROVENT ......................... 88
ATROVENT HFA ................ 88
AUBAGIO ............................ 81
AUGMENTIN ................ 12, 13
AUGMENTIN ES-600 ......... 12
AUGMENTIN XR................ 13
AUVI-Q ................................ 44
AVALIDE............................. 40
AVANDAMET..................... 24
AVANDARYL ..................... 24
AVANDIA............................ 24
AVAPRO .............................. 40
AVAR-E LS CREAM .......... 58
AVC ...................................... 29
AVELOX .............................. 13
AVELOX ABC PACK ......... 13
AVIDOXY............................ 14
I-2
AVINZA ................................. 2
AVODART ........................... 83
AVONEX.............................. 84
AVONEX
ADMINISTRATION PACK
........................................... 84
AXERT ................................. 30
AXID..................................... 71
AXIRON ............................... 75
AYGESTIN........................... 78
AZASAN .............................. 80
AZASITE.............................. 68
azathioprine .......................... 80
AZATHIOPRINE ................. 83
azelastine hcl......................... 70
AZELEX ............................... 58
AZILECT.............................. 34
azithromycin.......................... 11
AZITHROMYCIN................ 12
AZOPT.................................. 85
AZOR.................................... 44
AZULFIDINE....................... 13
bacitracin .................. 10, 60, 67
BACITRACIN ...................... 61
bacitracin/‌polymyxin b sulfate
........................................... 67
baclofen................................. 89
BACLOFEN ......................... 90
BACTRIM ............................ 13
BACTRIM DS ...................... 13
BACTROBAN...................... 61
BACTROBAN NASAL ....... 61
balsalazide disodium............. 81
BANZEL............................... 18
BARACLUDE ...................... 38
BECONASE AQ................... 87
BELLADONNA ................... 17
benazepril hcl........................ 40
benazepril/‌hydrochlorothiazide
........................................... 40
BENICAR ............................. 40
BENICAR HCT .................... 40
BENSAL HP......................... 58
BENTYL............................... 73
BENZAC AC ........................ 58
BENZAC W 10..................... 58
BENZAC W 2.5.................... 58
BENZAC W 5....................... 58
BENZACLIN........................ 61
BENZAMYCIN.................... 61
BENZEFOAM ULTRA........ 58
benzonatate ........................... 51
benzoyl peroxide ............. 57, 58
BENZOYL PEROXIDE ....... 57
benzoyl peroxide&skin cleansr5
........................................... 56
benztropine mesylate............. 34
BENZTROPINE MESYLATE
........................................... 34
BEPREVE............................. 70
BESIVANCE ........................ 68
BETAGAN ........................... 85
BETAMETHASONE ........... 77
BETAMETHASONE
ACETATE ........................ 77
betamethasone dipropionate. 62
BETAMETHASONE
DIPROPIONATE ............. 63
BETAMETHASONE SODIUM
PHOSPHATE ................... 77
betamethasone valerate .. 62, 63
BETAMETHASONE
VALERATE ..................... 63
betamethasone/‌propylene glyc
........................................... 62
BETAPACE.......................... 43
BETASERON ....................... 84
betaxolol hcl.................... 42, 85
bethanechol chloride............. 82
BETHANECHOL CHLORIDE
........................................... 83
BETIMOL............................. 85
BETOPTIC S ........................ 85
BEYAZ ................................. 50
BIAXIN................................. 12
BIAXIN XL .......................... 12
bicalutamide.......................... 14
BIDIL.................................... 48
BILTRICIDE ........................ 33
BINOSTO ............................. 82
bisoprolol fumarate............... 42
bisoprolol fumarate/‌hctz ....... 42
BLEPHAMIDE..................... 68
BLEPHAMIDE S.O.P. ......... 68
BONIVA ............................... 82
BOSULIF.............................. 16
BOTOX................................. 84
BREO ELLIPTA................... 87
BREVICON .......................... 50
BRILINTA............................ 39
brimonidine tartrate.............. 85
BROMDAY .......................... 69
bromfenac sodium................. 69
bromocriptine mesylate......... 34
BROMOCRIPTINE
MESYLATE ..................... 34
bromphenira/‌pseudoephed/‌code
in ....................................... 53
brompheniramin/‌pe/‌codeine . 51
brompheniramin/‌pe/‌dextrometh
or ....................................... 51
brompheniramine maleate ... 26,
27
brompheniramine tannate..... 26
bromphenrm/‌pseudoeph/‌dihydr
ocd..................................... 51
BRONCOTRON-D............... 53
BRONKIDS .......................... 53
BRONTUSS SF .................... 53
BROVANA........................... 88
BROVEX CB........................ 53
BROVEX CBX..................... 53
BROVEX PB C .................... 53
BROVEX PB CX.................. 53
BROVEX PEB DM .............. 54
BROVEX PSB DM .............. 54
budesonide ...................... 81, 87
BUDESONIDE MICRONIZED
........................................... 77
bumetanide............................ 45
BUPHENYL ......................... 73
buprenorphine hcl................... 8
I-3
buprenorphine hcl/‌naloxone hcl
............................................. 8
bupropion hcl ........................ 20
BUPROPION HCL............... 21
buspirone hcl......................... 82
BUSPIRONE HCL ............... 90
BUSULFEX.......................... 16
butalb/‌acetaminophen/‌caffeine1
butalbit/‌acetamin/‌caff/‌codeine 1
butalbital/‌acetaminophen ....... 1
butalbital/‌aspirin/‌caffeine... 5, 7
BUTISOL SODIUM............. 90
butorphanol tartrate ............... 1
BUTORPHANOL TARTRATE
............................................. 3
BUTRANS.............................. 3
BYDUREON ........................ 22
BYETTA............................... 22
BYSTOLIC ........................... 43
cabergoline ........................... 34
CADUET .............................. 46
CAFCIT ................................ 48
CAFERGOT ......................... 30
CAFFEINE CITRATE.......... 49
caffeine citrated .................... 48
CALAN................................. 43
CALAN SR........................... 43
calcipotriene ......................... 57
calcitonin,salmon,synthetic... 82
calcitriol.......................... 58, 82
calcium acetate ..................... 74
CAMBIA ................................ 6
CAMPRAL ............................. 8
CANASA .............................. 81
CANCIDAS .......................... 26
candesartan cilexetil ............. 40
candesartan/‌hydrochlorothiazid
........................................... 40
CANTIL................................ 73
CAPASTAT SULFATE ....... 31
CAPEX SHAMPOO............. 63
CAPHOSOL ......................... 66
CAPITAL W-CODEINE ........ 3
CAPRELSA .......................... 16
CAPSULE #1........................ 83
captopril................................ 40
captopril/‌hydrochlorothiazide
........................................... 41
CARAC................................. 58
CARAFATE ......................... 71
CARBAGLU ........................ 73
carbamazepine ...................... 17
CARBAMAZEPINE ............ 18
CARBAPHEN 12 ................. 54
CARBAPHEN 12 PED......... 54
CARBATROL ...................... 18
CARBATUSS-12.................. 54
CARBATUSS-CL ................ 54
carbidopa/‌levodopa .............. 34
carbidopa/‌levodopa/‌entacapone
........................................... 34
carbinoxamine maleate......... 26
car-b-pen ta/‌chlor-tan........... 51
car-b-pen ta/‌phenylephrine/‌pyr
........................................... 51
CARDENE SR...................... 44
CARDIZEM.......................... 43
CARDIZEM CD ................... 43
CARDIZEM LA ................... 43
CARDURA ........................... 39
CARDURA XL..................... 39
carisoprodol.......................... 89
CARISOPRODOL................ 90
carisoprodol/‌aspirin ............. 89
CARMOL HC....................... 63
CARNITOR .......................... 83
carteolol hcl .......................... 70
carvedilol .............................. 42
CASODEX............................ 15
CATAFLAM .......................... 6
CATAPRES .......................... 39
CATAPRES-TTS 1............... 39
CATAPRES-TTS 2............... 39
CATAPRES-TTS 3............... 39
CAVERJECT........................ 91
CAYSTON............................ 12
CEDAX................................. 11
CEENU ................................. 15
cefaclor ................................. 11
cefadroxil hydrate ................. 11
cefazolin sodium.................... 11
cefdinir .................................. 11
cefditoren pivoxil .................. 11
CEFEPIME ........................... 11
cefotetan disodium ................ 11
cefoxitin sodium/‌dextrose,iso 11
cefpodoxime proxetil............. 11
cefprozil................................. 11
CEFTAZIDIME.................... 11
CEFTAZIDIME-SODIUM
CARBONATE .................. 11
CEFTIN................................. 11
ceftriaxone sodium ................ 11
cefuroxime axetil................... 11
CELEBREX............................ 6
CELESTONE........................ 77
CELEXA............................... 21
CELLCEPT..................... 80, 81
CELONTIN........................... 18
CENESTIN ........................... 76
CENTANY ........................... 61
CENTANY AT ..................... 61
cephalexin ............................. 11
CERETEC............................. 66
CEREZYME ......................... 67
CESAMET............................ 32
CETACAINE........................ 58
CETACAINE ANESTHETIC
........................................... 58
cetirizine hcl.......................... 26
CETRAXAL ......................... 68
cevimeline hcl........................ 56
CHANTIX............................... 8
CHATEAL............................ 50
CHEMET .............................. 75
CHENODAL......................... 66
CHILDREN'S CLARITIN.... 26
CHILDREN'S ZYRTEC....... 26
CHILDREN'S ZYRTEC
HIVES RELIEF ................ 26
CHILD'S ZYRTEC ALLERGY
........................................... 26
I-4
chloral hydrate...................... 83
chloramphenicol sod succ..... 11
chlordiazepoxide hcl ............... 9
chlordiazepoxide/‌clidinium br
........................................... 17
chlorhexidine gluconate........ 56
chlor-mal/‌phenyleph/‌methscop
........................................... 26
chloroquine phosphate.......... 33
chlorothiazide ....................... 45
chlorpheniramine maleate .... 26
chlorpheniramine tannate..... 26
chlorpheniramine/‌codeine phos
........................................... 51
chlorpromazine hcl ............... 35
CHLORPROMAZINE HCL. 35
chlorpropamide..................... 23
chlorthalidone ....................... 45
chlorzoxazone ....................... 89
chlorzoxazone/‌acetaminophen
........................................... 89
cholestyramine (with sugar) . 45
CHOLESTYRAMINE RESIN
........................................... 46
cholestyramine/‌aspartame .... 46
CHOLINE MAGNESIUM
TRISALICYLAT................ 6
choline sal/‌mag salicylate....... 5
CHORIONIC
GONADOTROPIN........... 78
CIALIS.................................. 91
CICLODAN.......................... 25
ciclopirox .............................. 24
ciclopirox olamine ................ 24
cidofovir ................................ 38
cilostazol ............................... 39
CILOXAN............................. 68
cimetidine.............................. 71
CIMETIDINE ....................... 71
cimetidine hcl ........................ 71
CIMZIA ................................ 67
CIPRO................................... 13
CIPRO HC ............................ 68
CIPRO XR ............................ 13
CIPRODEX .......................... 68
ciprofloxacin hcl ....... 13, 67, 68
CIPROFLOXACIN HCL ..... 13
ciprofloxacin/‌ciprofloxa hcl.. 13
citalopram hydrobromide ..... 20
citric acid/‌sodium citrate ...... 86
CLAFORAN ......................... 11
CLARIFOAM EF ................. 58
CLARINEX .......................... 28
CLARINEX-D 12 HOUR..... 28
CLARINEX-D 24 HOUR..... 28
CLARIS ................................ 58
clarithromycin....................... 12
CLARITIN............................ 26
CLARITIN-D 12 HOUR ...... 26
CLEARPLEX V.................... 58
CLEARPLEX X.................... 58
clemastine fumarate .............. 26
CLEMASTINE FUMARATE
........................................... 28
CLEOCIN ............................. 29
CLEOCIN HCL .................... 10
CLEOCIN PALMITATE...... 10
CLEOCIN T.......................... 61
CLIMARA ............................ 76
CLIMARA PRO ................... 76
CLINDACIN P ..................... 61
CLINDAGEL........................ 61
clindamycin hcl ..................... 10
CLINDAMYCIN HCL ......... 10
clindamycin palmitate hcl ..... 10
clindamycin phos/‌benzoyl perox
........................................... 60
clindamycin phosphate.... 29, 60
CLINDESSE ......................... 29
CLINORIL.............................. 6
clobetasol propionate............ 62
CLOBETASOL PROPIONATE
........................................... 63
CLOBEX............................... 63
CLODERM ........................... 64
clomipramine hcl .................. 20
CLOMIPRAMINE HCL....... 21
clonazepam ............................. 9
CLONAZEPAM ..................... 9
clonidine................................ 39
clonidine hcl.......................... 39
CLONIDINE HCL................ 44
clonidine hcl/‌chlorthalidone . 40
clopidogrel bisulfate ............. 39
clorazepate dipotassium.......... 9
CLORPRES .......................... 40
clotrimazole........................... 24
CLOTRIMAZOLE ............... 25
clotrimazole/‌betamethasone dip
........................................... 24
clozapine ............................... 35
CLOZARIL........................... 35
CNL 8.................................... 25
COARTEM ........................... 33
codeine phos/‌acetaminophen .. 1
CODEINE PHOSPHATE....... 3
codeine sulfate ........................ 1
CODEINE SULFATE ............ 1
codeine/‌butalbital/‌asa/‌caffein. 1
codeine/‌carisoprodol/‌aspirin 90
COLAZAL............................ 81
colchicine .............................. 82
COLCHICINE ...................... 83
colchicine/‌probenecid ........... 82
COLCRYS ............................ 83
COLESTID ........................... 46
colestipol hcl ......................... 46
COLY-MYCIN S.................. 68
COLYTE with FLAVOR
PACKETS......................... 73
COMBIGAN......................... 86
COMBIPATCH .................... 76
COMBIVENT....................... 88
COMBIVENT RESPIMAT .. 88
COMBIVIR .......................... 37
COMETRIQ.......................... 16
COMPAZINE ....................... 32
COMPLERA......................... 37
COMTAN ............................. 34
CONCERTA ......................... 49
CONDYLOX ........................ 58
CONZIP .................................. 3
I-5
COPAXONE......................... 84
COPEGUS ............................ 38
CORDARONE...................... 42
CORDRAN ........................... 64
CORDRAN SP ..................... 64
COREG ................................. 43
COREG CR........................... 42
CORGARD ........................... 43
CORTEF ............................... 77
CORTENEMA...................... 64
CORTIFOAM ....................... 64
cortisone acetate ................... 76
CORTISONE ACETATE..... 77
CORTISPORIN .............. 61, 68
CORTISPORIN-TC.............. 68
CORVITE 150 ...................... 92
CORVITE FE........................ 92
CORZIDE ............................. 43
COSOPT ............................... 86
COSOPT PF.......................... 86
COTAB A ............................. 54
COTAB AX .......................... 54
COTABFLU ......................... 54
COUMADIN......................... 38
COZAAR .............................. 40
CREON ................................. 66
CRESTOR ............................ 47
cresyl ace/‌ben alc/‌butanol/‌ipa
........................................... 67
CRINONE............................. 78
CRIXIVAN ........................... 36
cromolyn sodium....... 70, 72, 89
CUBICIN .............................. 11
CUPRIMINE ........................ 75
CUTIVATE........................... 64
CUVPOSA............................ 72
CYCLESSA .......................... 50
cyclobenzaprine hcl .............. 89
CYCLOBENZAPRINE HCL90
cyclophosphamide................. 14
CYCLOPHOSPHAMIDE .... 15
CYCLOSET.......................... 22
cyclosporine .......................... 80
CYCLOSPORINE ................ 83
cyclosporine, modified .......... 80
CYMBALTA ........................ 21
cyproheptadine hcl................ 26
CYPROHEPTADINE HCL.. 28
CYSTADANE ...................... 83
CYSTAGON......................... 66
CYSTARAN ......................... 70
CYSTOSPAZ-M................... 17
CYTOMEL ........................... 80
CYTOTEC ............................ 71
D.H.E.45 ............................... 30
DALIRESP ........................... 89
danazol.................................. 75
DANAZOL ........................... 75
DANTRIUM ......................... 90
dantrolene sodium................. 89
DANTROLENE SODIUM... 90
dapsone ................................. 31
DAPSONE ............................ 31
DARAPRIM ......................... 33
DAYPRO ................................ 6
DAYTRANA ........................ 49
DDAVP................................. 78
DECADRON ........................ 69
DEL-AQUA-5....................... 58
DEL-MYCIN ........................ 61
DELOS.................................. 59
DELZICOL ........................... 81
DEMADEX........................... 45
demeclocycline hcl ................ 14
DEMEROL ......................... 3, 5
DEMSER .............................. 44
DEMULEN 1-50-21 ............. 50
DENAVIR............................. 58
DEPAKENE ......................... 18
DEPAKOTE ......................... 18
DEPAKOTE ER ................... 18
DEPAKOTE SPRINKLE ..... 18
DEPEN.................................. 75
DEPO-PROVERA ................ 78
DEPO-SUBQ PROVERA 104
........................................... 79
DEPO-TESTOSTERONE .... 75
DERMA-SMOOTHE-FS...... 64
DERMATOP ........................ 64
DERMOTIC.......................... 69
desipramine hcl..................... 20
desloratadine................... 27, 28
desmopressin acetate ............ 78
DESOGEN............................ 50
desogestrel-ethinyl estradiol. 49
desog-et estra/‌ethin estra...... 49
DESONATE ......................... 64
desonide ................................ 62
DESONIDE........................... 64
desoximetasone ..................... 62
DESOXIMETASONE .......... 64
DESOXYN ........................... 49
DESPEC................................ 54
DESPEC DM ........................ 53
DESPEC-DM........................ 54
DESPEC-EXP....................... 53
DESPEC-PDC ...................... 54
DESQUAM-X....................... 59
DESVENLAFAXINE ER..... 21
DETROL............................... 74
DETROL LA ........................ 74
dexamethasone...................... 77
DEXAMETHASONE........... 77
DEXAMETHASONE
INTENSOL ....................... 77
dexamethasone sod phosphate
........................................... 69
DEXAMETHASONE
SODIUM PHOSPHATE... 77
DEXASOL............................ 69
dexchlorpheniramine maleate26
DEXEDRINE........................ 49
DEXILANT .......................... 71
dexmethylphenidate hcl......... 48
DEXPAK .............................. 77
dextroamphetamine sulfate .. 48,
49
dextroamphetamine/‌amphetami
ne....................................... 48
dhcodeine bt/‌acetaminophn/‌caff
......................................... 1, 3
DIABETA ............................. 24
I-6
DIAMOX SEQUELS............ 86
DIASTAT ............................... 9
DIASTAT ACUDIAL ............ 9
diazepam ................................. 9
DIAZEPAM............................ 9
DIBENZYLINE.................... 39
diclofenac potassium............... 5
diclofenac sodium ............. 5, 69
DICLOFENAC SODIUM ...... 7
diclofenac sodium/‌misoprostol 6
dicloxacillin sodium .............. 12
dicyclomine hcl ..................... 72
DICYCLOMINE HCL.......... 17
didanosine ............................. 36
DIDRONEL .......................... 82
DIFFERIN ............................ 65
DIFICID................................ 12
diflorasone diacetate............. 62
DIFLUCAN .......................... 25
diflunisal ................................. 6
DIFLUNISAL ......................... 7
digoxin................................... 44
DIGOXIN ............................. 44
dihydrocodeine/‌aspirin/‌caffein 2
dihydrocodeine/‌guaifenesin .. 51
dihydroergotamine mesylate. 30
DIHYDROERGOTAMINE
MESYLATE ..................... 30
DILACOR XR ...................... 43
DILANTIN ........................... 18
DILANTIN-125 .................... 18
DILATRATE-SR.................. 48
DILAUDID ......................... 2, 3
diltiazem hcl .......................... 43
DILTIAZEM HCL................ 43
dimenhydrinate ..................... 32
DIMENHYDRINATE .......... 28
DIOVAN............................... 40
DIOVAN HCT...................... 40
DIPENTUM.......................... 81
diphenhydramine hcl. 26, 29, 57
DIPHENHYDRAMINE HCL
........................................... 28
diphenoxylate hcl/‌atropine.... 72
DIPROLENE ........................ 64
DIPROLENE AF .................. 64
DIPROSONE ........................ 64
dipyridamole ......................... 39
DIPYRIDAMOLE ................ 44
disopyramide phosphate ....... 41
disulfiram ................................ 8
DISULFIRAM ...................... 83
DITROPAN XL .................... 74
DIURIL ................................. 45
divalproex sodium................. 17
DIVIGEL .............................. 76
dm/‌phenyleph/‌chlorpheniramin
e......................................... 51
d-methorphan hb/‌p-epd hcl/‌bpm
..................................... 52, 54
hcl/‌cp........................... 52, 53
d-methorphan hb/‌prometh hcl52
DOLGIC PLUS....................... 3
DOLOGESIC.......................... 3
DOLOPHINE HCL................. 3
DONATUSS DC................... 54
DONATUSSIN DM ............. 54
donepezil hcl ......................... 19
DONNATAL ........................ 17
DORAL................................... 9
DORIBAX ............................ 12
DORYX ................................ 14
dorzolamide hcl..................... 85
dorzolamide hcl/‌timolol maleat
........................................... 85
DOVONEX........................... 59
doxazosin mesylate................ 39
doxepin hcl ............................ 20
DOXEPIN HCL .................... 21
doxycycline hyclate ............... 14
DOXYCYCLINE HYCLATE
........................................... 14
doxycycline monohydrate...... 14
doxylamine succinate ............ 26
DRITHOCREME HP ........... 59
dronabinol............................. 32
DROXIA ............................... 15
DRYSOL .............................. 59
DUAC CS ............................. 61
DUETACT............................ 24
DUEXIS.................................. 7
DULERA .............................. 87
DUONEB.............................. 88
DURAFLU............................ 54
DURAGESIC.......................... 3
DURATUSS AC 12.............. 54
DURAXIN .............................. 3
DUREZOL............................ 69
DUTOPROL ................... 42, 43
DYAZIDE............................. 45
DYMISTA ............................ 70
DYNACIN ............................ 14
DYRENIUM ......................... 45
E.E.S. 200 ............................. 12
EC-NAPROSYN .................... 7
econazole nitrate................... 24
ECONAZOLE NITRATE .... 25
EDARBI................................ 40
EDARBYCLOR ................... 40
EDECRIN ............................. 45
EDEX.................................... 91
EDLUAR .............................. 90
EDURANT ........................... 37
EFFER-K .............................. 86
EFFEXOR XR ...................... 21
EFFIENT............................... 39
EFUDEX............................... 59
ELAPRASE .......................... 67
ELELYSO............................. 67
ELESTAT ............................. 70
ELESTRIN............................ 76
ELIDEL................................. 63
ELIQUIS ............................... 38
ELLA .................................... 50
ELMIRON ............................ 83
ELOCON .............................. 64
ELSPAR................................ 16
EMADINE ............................ 70
EMBEDA................................ 3
EMCYT................................. 15
EMEND ................................ 32
I-7
EMERSAL............................ 59
EMLA ..................................... 8
EMSAM................................ 21
EMTRIVA ............................ 36
ENABLEX............................ 74
enalapril maleate .................. 41
ENALAPRIL MALEATE .... 41
enalapril/‌hydrochlorothiazide
........................................... 41
ENBREL ............................... 81
ENDOMETRIN .................... 79
ENJUVIA.............................. 76
enoxaparin sodium................ 38
entacapone ............................ 34
ENTEX ................................. 54
ENTOCORT EC ................... 81
EPICERAM .......................... 66
EPIDUO................................ 65
EPIFOAM ............................. 64
epinastine hcl ........................ 70
EPIPEN 2-PAK..................... 44
EPIPEN JR 2-PAK ............... 44
EPIVIR.................................. 36
EPIVIR HBV ........................ 36
eplerenone............................. 47
EPOGEN............................... 38
eprosartan mesylate .............. 40
EPZICOM ............................. 36
EQUETRO............................ 18
ergoloid mesylates ................ 82
ERGOLOID MESYLATES.. 91
ERGOMAR .......................... 30
ergotamine tartrate/‌caffeine . 30
ERIVEDGE........................... 16
ERTACZO ............................ 25
ery e-succ/‌sulfisoxazole ........ 12
ERYGEL............................... 61
ERYPED 200 ........................ 12
ERYPED 400 ........................ 12
ERY-TAB ............................. 12
ERYTHROMYCIN .............. 12
erythromycin base........... 12, 67
erythromycin base/‌ethanol.... 61
erythromycin ethylsuccinate . 12
ERYTHROMYCIN
ETHYLSUCCINATE ....... 12
erythromycin stearate ........... 12
erythromycin/‌benzoyl peroxide
........................................... 61
escitalopram oxalate............. 20
ESGIC ..................................... 3
ESGIC-PLUS.......................... 3
estazolam................................. 9
ESTRACE............................. 76
estradiol ................................ 75
ESTRADIOL MICRONIZED
........................................... 76
estradiol/‌norethindrone acet. 75
ESTRASORB ....................... 76
ESTRING.............................. 76
ESTRIOL .............................. 76
ESTRIOL MICRONIZED .... 76
ESTROGEL .......................... 76
estrogen,ester/‌me-testosterone
........................................... 75
ESTRONE............................. 76
ESTRONE SULFATE
PIPERAZINE.................... 76
estropipate............................. 75
ESTROSTEP FE................... 50
ethambutol hcl....................... 31
ETHAMBUTOL HCL .......... 31
ethinyl estradiol/‌drospirenone
........................................... 50
ethosuximide ......................... 17
ETHOSUXIMIDE ................ 18
ethynodiol d-ethinyl estradiol 50
ETHYOL............................... 84
etidronate disodium .............. 82
etodolac................................... 5
ETOPOPHOS ....................... 16
etoposide ............................... 15
ETOPOSIDE......................... 15
EURAX................................. 66
EVAMIST............................. 76
EVISTA ................................ 76
EVOCLIN ............................. 61
EVOXAC.............................. 56
EXACTACAIN..................... 59
EXALGO ................................ 3
EXELDERM......................... 25
EXELON............................... 19
exemestane ............................ 15
EXFORGE ............................ 44
EXFORGE HCT ................... 44
EXJADE ............................... 75
EXTAVIA............................. 84
EXTINA................................ 25
FACTIVE.............................. 13
famciclovir ............................ 37
famotidine ............................. 71
FAMOTIDINE...................... 71
FAMVIR ............................... 38
FANAPT ............................... 35
FARESTON.......................... 15
FAZACLO ............................ 35
felbamate............................... 17
FELBATOL .......................... 18
FELDENE............................... 7
felodipine............................... 44
FEM PH ................................ 29
FEMARA.............................. 15
FEMCON FE ........................ 50
FEMHRT .............................. 76
FEMRING ............................ 76
fenofibrate ............................. 46
fenofibrate nanocrystallized.. 46
fenofibrate,micronized .......... 46
fenofibric acid ....................... 46
FENOGLIDE ........................ 47
fenoprofen calcium.................. 6
fentanyl.................................... 1
fentanyl citrate ........................ 1
FENTORA .............................. 3
FERRIPROX ........................ 75
FEXMID ............................... 90
fexofenadine hcl .............. 26, 28
fexofenadine/‌pseudoephedrine
........................................... 27
FIBRICOR ............................ 47
FINACEA ............................. 59
FINACEA PLUS .................. 59
I-8
finasteride ............................. 82
FIORICET............................... 3
FIORICET with CODEINE.... 3
FIORINAL.............................. 7
FIORINAL with CODEINE #3
............................................. 3
FIRMAGON ......................... 16
FIRST-BXN.......................... 25
FIRST-DUKE'S .................... 25
FIRST-HYDROCORTISONE
........................................... 64
FIRST-MARY'S ................... 25
FIRST-PROGESTERONE
VGS 100 ........................... 79
FIRST-PROGESTERONE
VGS 200 ........................... 79
FIRST-PROGESTERONE
VGS 25 ............................. 79
FIRST-PROGESTERONE
VGS 400 ........................... 79
FIRST-PROGESTERONE
VGS 50 ............................. 79
FLAGYL............................... 33
FLAGYL ER......................... 33
FLAREX ............................... 69
flavoxate hcl .......................... 74
flecainide acetate .................. 42
FLECTOR............................... 7
FLEXERIL............................ 90
FLOMAX.............................. 91
FLONASE ............................ 87
FLO-PRED ........................... 77
FLOVENT DISKUS............. 87
FLOVENT HFA ................... 87
FLOXIN................................ 68
fluconazole ............................ 24
FLUCONAZOLE ................. 25
flucytosine ............................. 24
fludarabine phosphate .......... 16
fludrocortisone acetate ......... 77
FLUDROCORTISONE
ACETATE ........................ 77
FLUMADINE ....................... 37
flunisolide.............................. 87
FLUNISOLIDE..................... 77
fluocinolone acetonide .......... 62
FLUOCINOLONE
ACETONIDE.................... 64
fluocinolone acetonide oil..... 69
fluocinolone/‌shower cap ....... 62
fluocinonide........................... 62
FLUOCINONIDE................. 64
fluorometholone .................... 69
FLUOROMETHOLONE...... 69
FLUOROPLEX .................... 59
fluorouracil ........................... 57
FLUOROURACIL................ 15
fluoxetine hcl......................... 20
FLUOXETINE HCL............. 21
fluoxymesterone .................... 75
fluphenazine hcl .................... 35
flurazepam hcl......................... 9
flurbiprofen ............................. 6
FLURBIPROFEN ................... 7
flurbiprofen sodium............... 69
flutamide ............................... 15
fluticasone propionate ... 62, 63,
87
FLUTICASONE
PROPIONATE.................. 77
fluvastatin sodium ................. 46
fluvoxamine maleate ....... 20, 21
FML ...................................... 69
FML FORTE......................... 69
FML S.O.P. ........................... 69
FOCALIN ............................. 49
FOCALIN XR....................... 49
folic acid................................ 92
fondaparinux sodium ............ 38
FOOD COLOR GREEN....... 83
FORADIL ............................. 88
FORFIVO XL ....................... 21
FORTAMET ......................... 22
FORTEO ............................... 82
FORTESTA .......................... 75
FORTICAL ........................... 82
FOSAMAX ........................... 82
FOSAMAX PLUS D ............ 82
foscarnet sodium ................... 37
fosinopril sodium .................. 41
fosinopril/‌hydrochlorothiazide
........................................... 41
fosphenytoin sodium.............. 19
FOSRENOL.......................... 74
FRAGMIN ............................ 38
FROVA ................................. 31
FULYZAQ............................ 73
FURADANTIN..................... 10
furosemide............................. 45
FUSION PLUS ..................... 92
FUZEON............................... 37
gabapentin............................. 17
GABAPENTIN ..................... 18
GABITRIL............................ 18
galantamine hbr .................... 19
GARAMYCIN...................... 68
GASTRINEX NF.................. 72
GASTROCROM................... 73
GELFILM ............................. 70
GELNIQUE .......................... 74
gemfibrozil ............................ 46
GENERESS FE..................... 50
gentamicin sulfate ........... 61, 67
GENTAMICIN SULFATE..... 9
GEODON.............................. 35
GILENYA............................. 84
GILPHEX TR ....................... 54
GILTUSS .............................. 54
GILTUSS PEDIATRIC ........ 54
GILTUSS TR ........................ 54
GLEEVEC ............................ 16
glimepiride ............................ 23
glipizide................................. 23
GLIPIZIDE ........................... 24
glipizide/‌metformin hcl ......... 23
GLUCAGEN......................... 83
GLUCAGON EMERGENCY
KIT.................................... 83
GLUCOPHAGE ................... 22
GLUCOPHAGE XR............. 22
GLUCOTROL ...................... 24
GLUCOTROL XL ................ 24
I-9
GLUCOVANCE ................... 24
GLUMETZA......................... 22
glyburide ............................... 23
GLYBURIDE ....................... 24
glyburide,micronized ............ 23
glyburide/‌metformin hcl........ 24
glycopyrrolate ....................... 72
GLYCOPYRROLATE ......... 17
GLYNASE............................ 24
GLYSET ............................... 22
GOLYTELY ................... 73, 74
GORDOFILM....................... 59
GORDO-UREA .................... 59
GRALISE.............................. 18
granisetron hcl ...................... 32
GRIFULVIN V ..................... 25
griseofulvin ultramicrosize ... 25
griseofulvin,microsize ..... 24, 25
GRIS-PEG ............................ 25
guaifen/‌dm hb/‌p-ephedrine/‌bpm
........................................... 52
guaifen/‌d-methorphan
hb/‌pe/‌bpm.......................... 52
guaifen/‌theop anhyd/‌p-ephed 28
guaifenesin ............................ 52
guaifenesin/‌codeine phosphate
..................................... 52, 53
guaifenesin/‌dextromethorphan
........................................... 52
guaifenesin/‌dm/‌pseudoephedrin
e................................... 52, 53
guaifenesin/‌d-methorphan
hb/‌pe.................................. 52
guaifenesin/‌dyphylline .......... 89
guaifenesin/‌hydrocodone bit. 52
guaifenesin/‌p-ephed hcl/‌cod . 52
guaifenesin/‌phenylephrine hcl
........................................... 52
guaifenesin/‌pseudoephedrne hcl
........................................... 52
guaifenesin/‌theophylline ....... 89
GUANABENZ ACETATE .. 44
guanfacine hcl....................... 39
GUANFACINE
HYDROCHLORIDE ........ 44
guanidine hcl......................... 82
GYNAZOLE 1...................... 29
HALCION............................... 9
HALFAN .............................. 33
HALFLYTELY-BISACODYL
........................................... 74
halobetasol propionate ......... 62
HALOG................................. 64
HALONATE......................... 64
HALONATE PAC ................ 64
haloperidol............................ 35
HALOPERIDOL................... 35
haloperidol lactate ................ 35
hc/‌pramox hcl/‌cl-xylenol/‌water
........................................... 69
hc/‌pramoxine hcl/‌chloroxylenol
........................................... 69
HECORIA............................. 80
HECTOROL ......................... 82
HELIDAC ............................. 73
heparin sodium,porcine ........ 38
heparin sodium,porcine/‌pf .... 38
HEPSERA............................. 38
HEXALEN............................ 15
HIPREX ................................ 10
homatropine hbr.................... 70
HORIZANT .......................... 18
HUMALOG .......................... 23
HUMALOG MIX 50-50 ....... 23
HUMALOG MIX 75-25 ....... 23
HUMIRA .............................. 81
HUMULIN 70-30 ................. 23
HUMULIN N........................ 23
HUMULIN R ........................ 23
HYCAMTIN ......................... 15
HYCET ................................... 3
hydralazine hcl...................... 44
HYDRALAZINE HCL......... 44
HYDREA.............................. 15
HYDRO 35 ........................... 59
hydrochlorothiazide .............. 45
HYDROCHLOROTHIAZIDE
........................................... 45
hydrocodone bit/‌acetaminophen
......................................... 1, 3
hydrocodone bit/‌homatrop mebr ....................................... 52
hydrocodone/‌chlorphen polis 52
hydrocodone/‌ibuprofen ....... 1, 2
hydrocort/‌pramoxin/‌emol/‌pram
#1....................................... 62
hydrocortisone ................ 63, 77
HYDROCORTISONE.......... 64
hydrocortisone ac/‌lidocaine.. 62
hydrocortisone acetate.......... 62
HYDROCORTISONE
ACETATE ........................ 64
hydrocortisone acetate/‌aloe v62
hydrocortisone acetate/‌urea . 62
hydrocortisone butyrate ........ 63
hydrocortisone valerate ........ 63
hydrocortisone/‌iodoquinol.... 63
hydrocortisone/‌lidocaine/‌aloe
........................................... 63
hydrocortisone/‌pramoxine .... 63
hydromorphone hcl ............. 1, 2
HYDROMORPHONE HCL... 3
hydroxychloroquine sulfate... 33
hydroxyurea .......................... 15
HYDROXYUREA................ 15
hydroxyzine hcl ..................... 82
HYDROXYZINE HCL ........ 28
hydroxyzine pamoate ............ 82
HYDROXYZINE PAMOATE
........................................... 28
hyoscyamine sulfate ........ 17, 72
HYOSCYAMINE SULFATE
........................................... 17
HYPER-SAL ........................ 86
HYZAAR.............................. 40
ibandronate sodium .............. 82
IBUDONE............................... 3
ibuprofen ................................. 6
IBUPROFEN .......................... 7
ibuprofen/‌oxycodone hcl......... 1
I-10
ICLUSIG............................... 16
ILARIS.................................. 81
ILEVRO................................ 69
ILOTYCIN............................ 68
IMDUR ................................. 48
imipramine hcl ...................... 20
IMIPRAMINE HCL ............. 21
imipramine pamoate ............. 20
imiquimod ............................. 57
IMITREX.............................. 31
IMURAN .............................. 80
INCIVEK .............................. 37
INCRELEX........................... 78
indapamide............................ 45
INDERAL LA....................... 43
INDOCIN................................ 7
indomethacin........................... 6
INDOMETHACIN ................. 7
INFERGEN........................... 37
INLYTA................................ 16
INNOPRAN XL.................... 43
INOVA 4-1 ........................... 59
INOVA 8-2 ........................... 59
INSPRA ................................ 47
INTELENCE......................... 36
INTERMEZZO ..................... 90
INTRON A............................ 37
INTUNIV.............................. 49
INVANZ ............................... 12
INVEGA ............................... 35
INVIRASE............................ 36
INVOKANA ......................... 22
iodine/‌potassium iodide ........ 57
IOPIDINE ............................. 70
ipratropium bromide............. 88
IPRATROPIUM BROMIDE 89
ipratropium/‌albuterol sulfate 88
irbesartan.............................. 40
irbesartan/‌hydrochlorothiazide
........................................... 40
iron &iron asp gly/‌fa/‌mv,min38
........................................... 92
ISENTRESS.......................... 36
ISOCHRON .......................... 48
ISOLYTE S........................... 87
isomethept/‌acetaminop/‌dichlph
n......................................... 30
isometheptene/‌acetaminoph/‌caff
............................................. 1
isoniazid ................................ 31
isopropamide/‌prochlorperazine
........................................... 72
ISOPTO ATROPINE............ 70
ISOPTO CARPINE ........ 85, 86
ISOPTO HOMATROPINE .. 70
ISOPTO HYOSCINE ........... 70
ISORDIL............................... 48
ISORDIL TITRADOSE........ 48
isosorbide dinitrate ............... 47
isosorbide mononitrate ......... 48
isotretinoin ............................ 58
isoxsuprine hcl ...................... 44
isradipine .............................. 44
ISTALOL.............................. 86
itraconazole........................... 24
ITRACONAZOLE................ 25
JAKAFI................................. 16
JALYN.................................. 83
JANUMET............................ 22
JANUMET XR ..................... 22
JANUVIA ............................. 22
JENTADUETO..................... 22
JUVISYNC ........................... 22
KADIAN................................. 4
KALETRA............................ 36
KALYDECO......................... 89
kanamycin sulfate.................. 10
KAPVAY.............................. 49
KAZANO.............................. 22
KEFLEX ............................... 11
KENALOG ........................... 64
KEPIVANCE........................ 56
KEPPRA ............................... 18
KEPPRA XR......................... 18
KERAFOAM ........................ 59
KERALYT............................ 59
KERALYT SCALP .............. 59
KERLONE............................ 43
KEROL AD .......................... 59
KEROL ZX........................... 59
KETEK ................................. 12
ketoconazole.......................... 24
KETOCONAZOLE .............. 25
KETODAN ........................... 25
ketoprofen ............................... 6
KETOPROFEN ...................... 7
ketorolac tromethamine .... 6, 69
KETOROLAC
TROMETHAMINE ............ 7
KINERET ............................. 81
KLARON.............................. 61
KLONOPIN ............................ 9
K-LOR .................................. 86
KOMBIGLYZE XR.............. 22
KORLYM ............................. 23
K-PHOS NEUTRAL ............ 87
K-PHOS NO.2 ...................... 86
K-PHOS ORIGINAL............ 86
KRISTALOSE ...................... 72
K-TAB .................................. 86
KUVAN ................................ 67
labetalol hcl .......................... 42
LAC-HYDRIN...................... 59
LACRISERT......................... 70
LACTICARE-HC ................. 64
lactulose ................................ 72
LAMICTAL.......................... 19
LAMICTAL BLUE .............. 18
LAMICTAL GREEN............ 18
LAMICTAL ODT................. 19
LAMICTAL ODT BLUE ..... 18
LAMICTAL ODT GREEN .. 19
LAMICTAL ODT ORANGE19
LAMICTAL ORANGE ........ 18
LAMICTAL XR ................... 19
LAMICTAL XR BLUE........ 19
LAMICTAL XR GREEN ..... 19
LAMICTAL XR ORANGE.. 19
LAMISIL .............................. 25
lamivudine............................. 36
lamivudine/‌zidovudine .......... 36
lamotrigine...................... 17, 18
I-11
LANOXIN ............................ 44
lansoprazole.......................... 71
LANSOPRAZOLE ............... 71
LANTUS............................... 23
LANTUS SOLOSTAR ......... 23
LASIX................................... 45
LASTACAFT ....................... 70
latanoprost ............................ 85
LATUDA .............................. 35
LAZANDA ............................. 4
leflunomide............................ 80
LESCOL ............................... 47
LESCOL XL ......................... 47
LETAIRIS............................. 91
letrozole................................. 15
leucovorin calcium................ 82
LEUCOVORIN CALCIUM . 83
LEUKERAN ......................... 15
LEUKINE ............................. 38
leuprolide acetate.................. 16
LEVACET .............................. 7
levalbuterol hcl ..................... 88
LEVAQUIN.......................... 13
LEVATOL ............................ 43
LEVBID................................ 17
LEVEMIR............................. 23
LEVEMIR FLEXPEN .......... 23
levetiracetam......................... 17
LEVITRA ............................. 91
levobunolol hcl...................... 85
levocarnitine ......................... 82
LEVOCARNITINE .............. 83
levocarnitine (with sugar)..... 82
levocetirizine dihydrochloride
........................................... 27
levofloxacin ..................... 13, 67
LEVOFLOXACIN
HEMIHYDRATE ............. 13
levonorgestrel ....................... 50
levonorgestrel-eth estradiol .. 50
levorphanol tartrate ................ 1
LEVORPHANOL TARTRATE
............................................. 4
LEVOTHROID..................... 79
levothyroxine sodium ............ 79
LEVOTHYROXINE SODIUM
........................................... 79
LEVOXYL............................ 79
LEVSIN ................................ 73
LEVSIN-SL .......................... 73
LEXAPRO ............................ 21
LEXIVA................................ 36
LIALDA................................ 81
LIBRAX................................ 17
lidocaine.................................. 8
LIDOCAINE........................... 8
lidocaine hcl...................... 8, 57
LIDOCAINE HCL.................. 8
lidocaine/‌prilocaine ................ 8
LIDODERM ........................... 8
LINCOCIN ........................... 11
lindane................................... 66
LINZESS............................... 66
liothyronine sodium .............. 79
LIOTHYRONINE SODIUM 80
LIPITOR ............................... 47
LIPOFEN .............................. 47
LIPTRUZET ......................... 47
lisinopril................................ 41
LISINOPRIL......................... 41
lisinopril/‌hydrochlorothiazide
........................................... 41
lithium carbonate .................. 48
lithium citrate........................ 48
LITHIUM CITRATE
TETRAHYDRATE........... 49
LITHOBID............................ 49
LITHOSTAT......................... 83
LIVALO................................ 47
l-norgest-eth estr/‌ethin estra. 50
LO LOESTRIN FE ............... 50
LOCOID ............................... 64
LODOSYN ........................... 34
LODRANE ........................... 28
LODRANE 24 ...................... 28
LOESTRIN ........................... 51
LOESTRIN 24 FE................. 50
LOESTRIN FE...................... 51
LOFIBRA ............................. 46
LOMOTIL............................. 73
LOPERAMIDE..................... 73
loperamide hcl ...................... 72
LOPID................................... 47
LOPRESSOR........................ 43
LOPRESSOR HCT............... 43
LOPROX .............................. 25
loratadine.............................. 27
loratadine/‌pseudoephedrine . 27
lorazepam................................ 9
LORAZEPAM ........................ 9
LORCET 10-650..................... 4
LORCET PLUS ...................... 4
LORTAB................................. 4
LORTUSS EX ...................... 54
LORZONE............................ 90
losartan potassium ................ 40
losartan/‌hydrochlorothiazide 40
LOSEASONIQUE ................ 51
LOTEMAX ........................... 69
LOTENSIN ........................... 41
LOTENSIN HCT .................. 41
LOTREL ............................... 44
LOTRISONE ........................ 25
LOTRONEX ......................... 66
lovastatin............................... 46
LOVAZA .............................. 46
LOVENOX ........................... 38
loxapine succinate................. 35
LOXITANE .......................... 35
LUFYLLIN ........................... 88
LUFYLLIN-GG.................... 89
LUMIGAN............................ 86
LUNESTA ............................ 90
LUVOX CR .......................... 21
LUXIQ .................................. 64
LYRICA................................ 18
LYSODREN ......................... 15
LYSTEDA ............................ 39
MACROBID ......................... 10
MACRODANTIN................. 10
mafenide acetate ................... 58
MAGNACET.......................... 4
I-12
magnesium sulfate................. 87
MALARONE........................ 33
malathion .............................. 66
mannitol/‌sorbitol solution..... 81
maprotiline hcl ...................... 20
MARINOL............................ 32
MARPLAN ........................... 21
MATULANE ........................ 15
MAVIK ................................. 41
MAXAIR AUTOHALER..... 88
MAXALT ............................. 30
MAXALT MLT .................... 30
MAXIDEX............................ 69
MAXIDONE........................... 4
MAXIFED CD...................... 54
MAXIFED CDX................... 54
MAXIFED-G CD.................. 54
MAXIFED-G CDX............... 54
MAXIFLU CD...................... 54
MAXIFLU CDX................... 54
MAXIPHEN CD................... 54
MAXIPHEN CDX ................ 54
MAXIPHEN DM .................. 54
MAXITROL ......................... 68
MAXZIDE ............................ 45
MAXZIDE-25 MG ............... 45
M-CLEAR WC ..................... 53
mebendazole.......................... 33
MEBENDAZOLE................. 33
meclizine hcl.......................... 32
MECLIZINE HCL ................ 32
meclofenamate sodium............ 6
MECLOFENAMATE
SODIUM............................. 7
MEDROL.............................. 77
medroxyprogesterone acet .... 78
medroxyprogesterone acetate 78
MEDROXYPROGESTERONE
ACETATE ........................ 79
mefenamic acid ....................... 6
mefloquine hcl....................... 33
MEGACE.............................. 15
MEGACE ES ........................ 15
megestrol acetate .................. 15
MEGESTROL ACETATE ... 15
MEKINIST ........................... 16
meloxicam ............................... 6
MELOXICAM........................ 7
melphalan hcl........................ 16
M-END DM .......................... 53
M-END PE............................ 53
M-END WC .......................... 53
MENEST............................... 76
MENOSTAR ........................ 76
MENTAX ............................. 25
meperidine hcl......................... 1
MEPERIDINE HCL ............... 4
meperidine hcl/‌pf .................... 1
meprobamate......................... 83
MEPRON.............................. 33
mercaptopurine ..................... 15
MERCAPTOPURINE .......... 15
MERREM ............................. 12
mesalamine w/‌cleansing wipes
........................................... 81
MESNEX .............................. 83
MESTINON.......................... 83
METADATE CD .................. 49
METADATE ER .................. 48
metaproterenol sulfate .......... 88
metaxalone ............................ 90
metformin hcl ........................ 22
METFORMIN
methadone hcl ......................... 1
METHADONE HCL .............. 4
METHADOSE........................ 2
methamphetamine hcl ........... 48
methazolamide ...................... 85
methen/‌m-blue/‌sal/‌na phos/‌hyos
........................................... 10
methen/‌sod phos/‌meth blue/‌hyos
........................................... 10
methenamine mandelate........ 10
methimazole .......................... 79
METHIMAZOLE ................. 79
METHITEST ........................ 75
methocarbamol ..................... 89
METHOCARBAMOL.......... 90
METHOCEL E 4 M.............. 83
methotrexate sodium ............. 15
methotrexate sodium/‌pf......... 15
methscopolamine bromide .... 72
METHSCOPOLAMINE
BROMIDE ........................ 17
methyclothiazide ................... 45
methyl salicylate...................... 7
methyldopa............................ 39
methyldopa/‌hydrochlorothiazid
e......................................... 39
methyldopate hcl ................... 40
methylergonovine maleate .... 83
METHYLIN.......................... 48
methylphenidate hcl .............. 48
METHYLPHENIDATE HCL
........................................... 89
methylprednisolone ............... 77
METHYLPREDNISOLONE
AC MICRO....................... 77
METHYLPREDNISOLONE
SODIUM SUCC ............... 77
metipranolol.......................... 85
metoclopramide hcl............... 72
METOCLOPRAMIDE HCL 73
METOCLOPRAMIDE HCL
INTENSOL ....................... 72
metolazone ............................ 45
metoprolol succinate............. 42
metoprolol tartrate................ 42
METOPROLOL TARTRATE
........................................... 43
metoprolol/‌hydrochlorothiazide
........................................... 42
METOZOLV ODT ............... 73
METROCREAM .................. 61
METROGEL......................... 61
METROGEL-VAGINAL ..... 29
METROLOTION.................. 61
metronidazole............ 29, 33, 61
METRONIDAZOLE ............ 33
MEVACOR .......................... 47
mexiletine hcl ........................ 42
I-13
MEXILETINE HCL ............. 42
MIACALCIN........................ 82
MICARDIS ........................... 40
MICARDIS HCT .................. 40
miconazole nitrate........... 24, 29
MICONAZOLE NITRATE .. 25
MICRONOR ......................... 51
MICROZIDE ........................ 45
MIDAMOR........................... 45
MIDAZOLAM........................ 9
midazolam hcl ......................... 9
midodrine hcl ........................ 39
MIDRIN................................ 31
MIGRALAM .......................... 4
MIGRANAL ......................... 31
MIGRATEN ........................... 4
MILLIPRED ......................... 77
MILLIPRED DP ................... 77
MINASTRIN 24 FE.............. 51
MINIPRESS.......................... 40
MINIVELLE......................... 76
MINOCIN ............................. 14
minocycline hcl ..................... 14
MINOCYCLINE HCL.......... 14
minoxidil ............................... 48
MIRAPEX ............................ 34
MIRAPEX ER ...................... 34
MIRCETTE........................... 51
mirtazapine ........................... 20
misoprostol............................ 71
MISOPROSTOL HPMC ...... 71
mitoxantrone hcl ................... 16
MOBAN................................ 35
MOBIC ................................... 7
modafinil ............................... 90
MODICON ........................... 51
moexipril hcl ......................... 41
moexipril/‌hydrochlorothiazide
........................................... 41
mometasone furoate .............. 63
MOMETASONE FUROATE78
MONODOX.......................... 14
montelukast sodium............... 87
MONUROL .......................... 10
MORGIDOX......................... 14
morphine sulfate.................. 1, 2
MORPHINE SULFATE ......... 4
morphine sulfate in 0.9 % nacl 1
morphine sulfate/‌d5w.............. 2
morphine sulfate/‌pf ................. 2
MOTOFEN ........................... 73
MOVIPREP .......................... 74
MOXATAG .......................... 13
MOXEZA ............................. 68
MOZOBIL ............................ 38
MS CONTIN........................... 4
MSIR....................................... 4
mth/‌me blue/‌sod
phos/‌phen/‌hyos.................. 10
MUGARD............................. 66
MULTAQ ............................. 42
mupirocin .............................. 61
MUPIROCIN ........................ 62
mupirocin calcium ................ 61
MUSE ................................... 91
MYAMBUTOL .................... 31
MYCAMINE ........................ 26
MYCOBUTIN ...................... 31
mycophenolate mofetil .......... 80
MYDFRIN ............................ 70
MYFORTIC.......................... 80
MYLERAN........................... 15
MYOZYME.......................... 67
MYRBETRIQ ....................... 74
MYSOLINE.......................... 19
MYTELASE ......................... 83
nabumetone ............................. 6
nadolol .................................. 42
nadolol/‌bendroflumethiazide 42
nafcillin sodium..................... 13
NAFRINSE DAILYNEUTRAL........................ 56
NAFTIN................................ 25
NAGLAZYME ..................... 67
nalbuphine hcl......................... 5
NALFON ................................ 7
naloxone hcl ............................ 8
naltrexone hcl.......................... 8
NAMENDA .......................... 19
NAMENDA XR.................... 19
naphazoline hcl ..................... 70
NAPRELAN ........................... 7
NAPROSYN ........................... 7
naproxen ................................. 6
NAPROXEN........................... 7
naproxen sodium..................... 6
naratriptan hcl ...................... 30
NARDIL ............................... 21
NASACORT AQ .................. 87
NASONEX ........................... 87
NATACYN ........................... 69
NATAZIA............................. 51
nateglinide............................. 22
NATROBA ........................... 66
NATURETIN-5 .................... 45
NEBUPENT.......................... 34
NEBUSAL ............................ 86
needles, insulin disposable.... 66
nefazodone hcl ...................... 20
NEO DM............................... 54
neo/‌polymyx b sulf/‌dexameth 67
NEOBENZ MICRO.............. 59
neomy sulf/‌bacitra/‌polymyxin b
........................................... 67
neomy sulf/‌bacitrac zn/‌poly .. 61
neomy sulf/‌bacitrac zn/‌poly/‌hc
........................................... 67
neomycin sulfate...................... 9
NEOMYCIN SULFATE ........ 9
neomycin/‌polymyxin b sulf/‌hc67
neomycin/‌polymyxn
b/‌gramicidin...................... 67
NEO-POLYCIN.................... 68
NEORAL .............................. 80
NEOSPORIN ........................ 68
NEOSPORIN G.U. IRRIGANT
........................................... 62
NEOSTIGMINE BROMIDE 83
neostigmine methylsulfate..... 83
NEPTAZANE ....................... 86
NESINA................................ 22
NEULASTA ......................... 38
I-14
NEUPOGEN ......................... 38
NEUPRO .............................. 34
NEURONTIN ....................... 19
NEVANAC ........................... 69
nevirapine ............................. 36
NEXAVAR ........................... 16
NEXIUM............................... 71
niacin..................................... 46
NIASPAN ............................. 46
nicardipine hcl ...................... 44
NICOTINE POLACRILEX.. 84
nifedipine............................... 44
NIFEDIPINE......................... 44
NILANDRON....................... 15
nimodipine............................. 44
NIMOTOP ............................ 44
NIRAVAM ............................. 9
nisoldipine............................. 44
NITRO-BID .......................... 48
NITRO-DUR......................... 48
nitrofurantoin........................ 10
NITROFURANTOIN ........... 10
nitrofurantoin macrocrystal.. 10
nitroglycerin.......................... 48
NITROLINGUAL................. 48
NITROMIST......................... 48
NITROSTAT ........................ 48
nizatidine............................... 71
NIZORAL ............................. 25
NIZORAL A-D..................... 25
NORCO .................................. 4
NORDETTE-28 .................... 51
noreth a-et estra/‌fe fumarate 50
noreth-ethinyl estradiol/‌iron. 50
norethind ac/‌ethinyl estradiol76
norethindrone........................ 50
norethindrone acetate ........... 78
NORETHINDRONE
ACETATE ........................ 79
norethindrone a-e estradiol .. 50
norethindrone-ethinyl estrad 50
norethindrone-mestranol ...... 50
norgestimate-ethinyl estradiol
........................................... 50
norgestrel-ethinyl estradiol... 50
NORINYL 1+35 ................... 51
NORINYL 1+50 ................... 51
NORITATE........................... 61
NOROXIN ............................ 13
NORPACE............................ 42
NORPACE CR ..................... 42
NORPRAMIN ...................... 21
NOR-Q-D.............................. 51
nortriptyline hcl .................... 20
NORTRIPTYLINE HCL ...... 21
NORVASC ........................... 44
NORVIR ............................... 37
NOTUSS-NX........................ 54
NOTUSS-NXD ..................... 54
NOVACORT ........................ 64
NOVOLIN 70-30 .................. 23
NOVOLIN 70-30 INNOLET 23
NOVOLIN N ........................ 23
NOVOLIN N INNOLET ...... 23
NOVOLIN R......................... 23
NOVOLOG........................... 23
NOVOLOG FLEXPEN ........ 23
NOVOLOG MIX 70-30........ 23
NOVOLOG MIX 70-30
FLEXPEN ......................... 23
NOXAFIL ............................. 25
NUCORT .............................. 64
NUCYNTA ............................. 4
NUCYNTA ER....................... 4
NUEDEXTA......................... 49
NULEV ................................. 73
NULOJIX.............................. 81
NULYTELY with FLAVOR
PACKS.............................. 74
NUMORPHAN....................... 4
NUVARING ......................... 50
NUVIGIL.............................. 90
NYDAMAX.......................... 61
NYMALIZE.......................... 45
nystatin.................................. 24
NYSTATIN........................... 25
nystatin/‌triamcin ................... 24
NYSTAT-RX........................ 25
octreotide acetate.................. 78
OCUFEN .............................. 70
OCUFLOX............................ 68
ofloxacin.......................... 13, 67
OFORTA .............................. 16
olanzapine ............................. 35
olanzapine/‌fluoxetine hcl ...... 20
OLEPTRO ER ...................... 21
OLUX-E................................ 64
OMECLAMOX-PAK ........... 71
omeprazole............................ 71
OMEPRAZOLE.................... 71
omeprazole magnesium......... 71
omeprazole/‌sodium bicarbonate
........................................... 71
OMNARIS ............................ 87
OMNIPRED.......................... 70
OMONTYS........................... 38
ondansetron........................... 32
ondansetron hcl..................... 32
ONFI ....................................... 9
ONGLYZA ........................... 22
ONMEL ................................ 25
ONSOLIS................................ 4
OPANA................................... 4
OPANA ER............................. 4
opium tincture ....................... 72
opium/‌belladonna alkaloids.... 2
OPTIMYD ............................ 68
OPTIPRANOLOL ................ 86
OPTIVAR ............................. 70
ORACEA .............................. 14
ORACIT................................ 87
ORAP.................................... 35
ORAPRED............................ 78
ORAPRED ODT................... 78
ORAVIG ............................... 56
ORBIVAN .............................. 4
ORBIVAN CF ........................ 4
ORENCIA............................. 81
ORFADIN............................. 67
orphenadrine citrate ............. 89
ORPHENADRINE CITRATE
........................................... 90
I-15
orphenadrine/‌aspirin/‌caffeine89
ORTHO EVRA..................... 50
ORTHO TRI-CYCLEN ........ 50
ORTHO TRI-CYCLEN LO.. 50
ORTHO-CEPT...................... 51
ORTHO-CYCLEN ............... 51
ORTHO-NOVUM ................ 51
OSENI................................... 23
OSMOPREP ......................... 74
OSPHENA ............................ 76
OTICIN HC .......................... 68
OVCON-35 ........................... 51
OVIDE .................................. 66
oxacillin sodium .................... 13
OXANDRIN ......................... 75
oxandrolone .......................... 75
OXANDROLONE................ 75
oxaprozin................................. 6
oxazepam................................. 9
oxcarbazepine ....................... 17
OXECTA ................................ 2
OXISTAT ............................. 25
OXSORALEN-ULTRA........ 59
OXTELLAR XR................... 19
oxybutynin chloride............... 74
OXYBUTYNIN CHLORIDE74
oxycodone hcl.......................... 2
oxycodone hcl/‌acetaminophen 2
oxycodone hcl/‌aspirin ............. 2
OXYCODONE
HYDROCHLORIDE .......... 4
OXYCONTIN......................... 4
oxymorphone hcl..................... 2
OXYTROL ........................... 74
PACNEX .............................. 59
PACNEX HP ........................ 59
PACNEX LP......................... 59
PACNEX MX ....................... 59
PALGIC ................................ 28
PAMELOR ........................... 21
pamidronate disodium .......... 82
PAMINE ............................... 73
PAMINE FORTE ................. 73
PAMINE FQ ......................... 17
PANATUSS DXP................. 54
PANATUSS DXP PEDIATRIC
........................................... 54
PANCREAZE ....................... 66
PANDEL............................... 64
PANOXYL 10 ...................... 59
PANOXYL 5 ........................ 59
PANOXYL AQ 2.5............... 59
PANOXYL AQ 5.................. 59
PANRETIN........................... 59
pantoprazole sodium............. 71
papaverine hcl....................... 44
PARCOPA ............................ 34
paregoric............................... 72
PARLODEL.......................... 34
PARNATE ............................ 21
paromomycin sulfate............. 33
paroxetine hcl........................ 20
PASER .................................. 31
PATADAY ........................... 70
PATANASE.......................... 29
PATANOL............................ 70
PAXIL................................... 21
PAXIL CR ............................ 21
PCE ....................................... 12
PEDIATEX TDM ................. 54
peg 3350/‌na sulf,bicarb,cl/‌kcl73
PEGANONE ......................... 18
PEGASYS............................. 37
PEGASYS PROCLICK ........ 37
PEGINTRON........................ 37
PEGINTRON REDIPEN ...... 37
pen g pot/‌dextrose-water....... 13
penicillin v potassium ........... 12
PENLAC ............................... 25
PENNSAID............................. 7
PENTASA ............................ 81
pentazocine hcl/‌acetaminophen
............................................. 2
pentazocine hcl/‌naloxone hcl.. 2
pentoxifylline......................... 39
PEPCID................................. 72
PEPCID RPD ........................ 72
p-epd tan/‌chlor-tan ............... 27
p-ephed hcl/‌chlor-mal/‌bell alk
........................................... 28
p-ephed hcl/‌codeine/‌guaifen . 52
p-ephed hcl/‌hydrocodone bit. 52
p-ephed hcl/‌triprolidine hcl . 27,
28
PERCOCET ............................ 4
PERCODAN ........................... 4
PERCOLONE ......................... 5
PERFOROMIST ................... 89
PERGOLIDE MESYLATE .. 34
PERIDEX.............................. 56
perindopril erbumine ............ 41
permethrin............................. 66
perphenazine ......................... 35
perphenazine/‌amitriptyline hcl
........................................... 20
PERSANTINE ...................... 39
PERTZYE ............................. 66
PEXEVA............................... 21
phenazopy hcl/‌hyoscy/‌butabarb
........................................... 57
phenazopyridine hcl .............. 91
PHENAZOPYRIDINE HCL 59
phenelzine sulfate.................. 20
PHENELZINE SULFATE.... 21
PHENFLU CD ...................... 55
PHENFLU CDX ................... 55
phenobarb/‌hyoscy/‌atropine/‌sco
p......................................... 17
phenobarbital........................ 17
phenyleph/‌dexchlor/‌methscopol
........................................... 27
phenylephrine hcl.................. 70
phenylephrine hcl/‌prometh hcl
........................................... 27
phenylephrine/‌brompheniramin
........................................... 29
phenylephrine/‌brompheniramin
e................................... 27, 28
phenylephrine/‌chlorpheniramin
e......................................... 27
phenylephrine/‌dhcodeine bt/‌cp
........................................... 52
I-16
phenylephrine/‌diphenhydramine
........................................... 27
phenylephrine/‌dp-hydram tan27
phenylephrine/‌p-tlox ci/‌cp .... 27
phenylephrine/‌pyrilamine tan 27
PHENYTEK ......................... 18
phenytoin............................... 18
PHENYTOIN SODIUM....... 19
phenytoin sodium extended ... 18
PHISOHEX........................... 62
PHOS-FLUR......................... 56
PHOSLO ............................... 74
PHOSLYRA ......................... 74
PHOSPHASAL..................... 10
PHOSPHOLINE IODIDE .... 85
phosphorus #1....................... 86
PHRENILIN FORTE.............. 5
PICATO ................................ 59
pilocarpine hcl ................ 56, 85
PILOCARPINE HCL ........... 86
PILOPINE HS....................... 85
pindolol ................................. 42
pioglitazone hcl..................... 24
pioglitazone hcl/‌glimepiride . 24
pioglitazone hcl/‌metformin hcl
........................................... 24
piroxicam ................................ 6
PIROXICAM .......................... 7
PLAN B ONE-STEP ............ 51
PLAQUENIL ........................ 33
PLASMA-LYTE 148............ 87
PLASMA-LYTE 56.............. 87
PLAVIX................................ 39
PLETAL................................ 39
PLEXION ............................. 59
PLIAGLIS............................... 8
podofilox ............................... 57
podophyllum resin................. 57
polyethylene glycol 3350....... 73
polymyxin b sulf/‌trimethoprim
........................................... 67
polymyxin b sulfate ............... 11
POLYTRIM .......................... 68
POLY-TUSSIN AC .............. 55
POLY-TUSSIN DHC ........... 55
POMALYST ......................... 16
PONSTEL ............................... 7
pot chloride/‌pot bicarb/‌cit ac 86
potassium bicarbonate/‌cit ac 86
potassium chloride ................ 86
potassium chloride-0.45% nacl
........................................... 87
potassium citrate................... 86
POTASSIUM CITRATE ...... 87
potassium citrate/‌citric acid . 86
potassium gluconate.............. 86
potassium iodide ................... 80
potassium iodide/‌iodine .. 79, 80
POTIGA................................ 19
PRADAXA ........................... 38
pramipexole di-hcl ................ 34
PRAMOSONE...................... 64
PRAMOSONE E .................. 63
pramoxine hcl........................ 57
PRANDIMET ....................... 23
PRANDIN............................. 22
PRAVACHOL ...................... 47
pravastatin sodium................ 46
prazosin hcl........................... 39
PRECOSE ............................. 23
PRED FORTE....................... 70
PRED MILD ......................... 69
PRED-G ................................ 68
prednicarbate........................ 63
prednisolone.......................... 77
PREDNISOLONE ................ 78
prednisolone acetate ............. 69
PREDNISOLONE ACETATE
MICRONIZE .................... 78
prednisolone sod phosphate. 69,
77
PREDNISOLONE SODIUM
PHOSPHATE ................... 78
prednisone............................. 77
PREDNISONE...................... 78
PREDNISONE INTENSOL . 77
PREFEST.............................. 76
PREGNENOLONE............... 84
PREMARIN.......................... 76
PREMPHASE ....................... 76
PREMPRO............................ 76
PREVACID .......................... 72
PREVACID 24HR ................ 71
PREVIDENT ........................ 56
PREVIDENT 5000 PLUS .... 56
PREVIDENT 5000
SENSITIVE ...................... 56
PREVPAC ............................ 72
PREZISTA............................ 36
PRIFTIN ............................... 31
PRILOSEC............................ 72
PRIMAQUINE ..................... 33
PRIMAXIN........................... 12
primidone .............................. 18
PRIMIDONE ........................ 49
PRIMLEV ............................... 5
PRIMSOL ............................. 10
PRINIVIL ............................. 41
PRINZIDE ............................ 41
PRISTIQ ER ......................... 21
PRIVIGEN............................ 81
PROAIR HFA....................... 88
probenecid............................. 83
procainamide hcl .................. 42
PROCARDIA ....................... 45
PROCARDIA XL ................. 45
PROCHIEVE ........................ 79
prochlorperazine maleate ..... 32
PROCHLORPERAZINE
MALEATE ....................... 35
PRO-CLEAR AC.................. 55
PROCRIT.............................. 38
PROCTOCORT .................... 64
PROCTOCREAM-HC.... 63, 64
PROCTOFOAM-HC ............ 64
PROGESTERONE ............... 79
PROGESTERONE
MICRONIZED ................. 79
progesterone,micronized....... 78
PROGLYCEM...................... 48
PROGRAF ............................ 81
PROLASTIN ........................ 89
I-17
PROLASTIN C..................... 89
PROLENSA.......................... 70
PROLEX DMX..................... 55
PROLIA ................................ 82
PROMACTA ........................ 39
promethazine hcl............. 27, 32
PROMETHAZINE HCL ...... 32
promethazine hcl/‌codeine ..... 52
promethazine/‌phenyleph/‌codein
e......................................... 52
PROMETRIUM.................... 79
PROMISEB .......................... 66
propafenone hcl .................... 42
propantheline bromide.......... 17
PROPANTHELINE
BROMIDE ........................ 17
proparacaine hcl................... 70
propranolol hcl ..................... 42
PROPRANOLOL HCL ........ 43
propranolol/‌hydrochlorothiazid
........................................... 42
propylthiouracil .................... 79
PRO-RED AC....................... 55
PROSCAR ............................ 84
PROSTIGMIN ...................... 84
PROTID ................................ 29
PROTONIX .......................... 72
PROTOPIC ........................... 64
protriptyline hcl .................... 20
PROVENTIL HFA ............... 89
PROVERA............................ 79
PROVIGIL............................ 91
PROZAC............................... 21
PROZAC WEEKLY............. 21
PRUDOXIN.......................... 59
pseudoephed & triprolid polist
........................................... 28
pseudoephed/‌chlorpheniramine
..................................... 27, 28
pseudoephedrine hcl/‌chlor-mal
........................................... 27
pseudoephedrine hcl/‌codeine 53
pseudoephedrine/‌cpm/‌methscop
ol ....................................... 27
PULMICORT ....................... 87
PULMICORT FLEXHALER87
PULMOZYME ..................... 67
PURINETHOL ..................... 15
PYLERA ............................... 72
pyrazinamide......................... 31
pyridostigmine bromide ........ 83
PYRIDOSTIGMINE
BROMIDE ........................ 84
pyrilamine/‌pe/‌dextromethorpha
n......................................... 53
QNASL ................................. 87
QUALAQUIN....................... 33
QUARTETTE ....................... 51
quazepam ................................ 9
QUESTRAN LIGHT ............ 47
quetiapine fumarate .............. 35
QUIC-K................................. 87
QUILLIVANT XR................ 49
quinapril hcl.......................... 41
quinapril/‌hydrochlorothiazide
........................................... 41
quinidine gluconate............... 42
quinidine sulfate.................... 42
quinine sulfate....................... 33
QVAR ................................... 87
RADIAPLEXRX .................. 84
ramipril ................................. 41
RANEXA.............................. 44
ranitidine hcl......................... 71
RANITIDINE HCL .............. 72
RAPAFLO ............................ 91
RAPAMUNE ........................ 80
RAYOS ................................. 78
RAZADYNE......................... 20
RAZADYNE ER .................. 19
REBETOL............................. 38
REBIF ................................... 85
REBIF REBIDOSE............... 84
RECTACORT-HC................ 64
RECTAGEL HC ................... 65
RECTIV ................................ 83
REDERM.............................. 63
REGLAN .............................. 73
REGRANEX......................... 59
RELAGARD......................... 29
RELENZA ............................ 37
RELISTOR ........................... 73
RELPAX ............................... 30
REMERON ........................... 21
REMICADE.......................... 85
REMODULIN....................... 91
RENAGEL............................ 74
RENVELA............................ 74
REQUIP ................................ 34
REQUIP XL.......................... 34
RESCON-JR. ........................ 29
RESCON-MX ....................... 29
RESCRIPTOR ...................... 36
RESCULA ............................ 86
reserpine ............................... 44
RESPA C&C IR.................... 55
RESTASIS ............................ 70
RESTORIL ............................. 9
RETIN-A............................... 65
RETIN-A MICRO ................ 65
RETROVIR........................... 37
REVATIO ............................. 91
REVIA .................................... 8
REVLIMID ........................... 16
REYATAZ............................ 36
RHEUMATREX................... 15
RHINOCORT AQUA........... 87
RIBATAB ....................... 37, 38
ribavirin ................................ 37
RIBAVIRIN.......................... 38
RIDAURA ............................ 81
RIFADIN .............................. 31
RIFAMATE .......................... 31
rifampin................................. 31
RIFAMPIN ........................... 31
rifampin/‌isoniazid ................. 31
RIFATER.............................. 31
RILUTEK ............................. 49
riluzole .................................. 49
rimantadine hcl ..................... 37
RIMSO-50 ............................ 59
RIOMET ............................... 23
I-18
RISPERDAL......................... 36
RISPERDAL M-TAB........... 36
risperidone ............................ 35
RITALIN............................... 49
RITALIN LA ........................ 49
RITALIN-SR ........................ 49
RITUXAN............................. 16
rivastigmine tartrate ............. 19
rizatriptan benzoate .............. 30
ROBAXIN ............................ 90
ROBAXIN-750 ..................... 90
ROBINUL............................. 73
ROBINUL FORTE ............... 73
ROCALTROL....................... 82
ropinirole hcl ........................ 34
ROSAC ................................. 59
ROSADAN ........................... 62
ROSANIL ............................. 60
ROSULA .............................. 60
ROSULA CLK ..................... 60
ROXICODONE ...................... 5
ROZEREM ........................... 91
RYBIX ODT........................... 5
RYDEX G............................. 55
RYNA-12.............................. 29
RYNA-12 S........................... 29
RYNA-12X ........................... 55
RYNATUSS ......................... 55
RYTHMOL........................... 42
RYTHMOL SR..................... 42
SABRIL ................................ 19
SAFYRAL ............................ 51
SALACYN............................ 60
SALAGEN............................ 56
sal-amide/‌acetaminophn/‌p-tlox2
SALEX.................................. 60
salicylic acid ......................... 57
salicylic acid/‌ammon lact/‌aloe
........................................... 57
salicylic acid/‌ceramide cmb #1
........................................... 57
salicylic acid/‌sulfur............... 57
SALKERA ............................ 60
salsalate .................................. 6
SALSALATE.......................... 7
SAMSCA .............................. 45
SANCTURA ......................... 74
SANCTURA XR .................. 74
SANCUSO............................ 32
SANDIMMUNE ................... 81
SANDOSTATIN................... 78
SANTYL............................... 60
SAPHRIS .............................. 36
SARAFEM............................ 22
SAVELLA ............................ 49
SCALACORT....................... 65
SEASONIQUE ..................... 51
SECONAL SODIUM ........... 91
SECTRAL............................. 43
selegiline hcl ......................... 34
selenium sulfide..................... 61
SELZENTRY........................ 36
SEMPREX-D........................ 29
SENSIPAR............................ 85
SEREVENT DISKUS........... 88
SEROMYCIN ....................... 31
SEROQUEL.......................... 36
SEROQUEL XR ................... 35
sertraline hcl ......................... 20
SERTRALINE HCL ............. 22
SFROWASA......................... 81
SIGNIFOR ............................ 85
sildenafil citrate .................... 91
SILENOR.............................. 22
SILVADENE ........................ 62
silver nitrate .......................... 61
silver nitrate applicator ........ 58
silver sulfadiazine ................. 61
SILVER SULFADIAZINE... 60
SIMBRINZA ........................ 86
SIMCOR ............................... 46
SIMPONI .............................. 85
SIMULECT........................... 85
simvastatin ............................ 46
SIMVASTATIN ................... 47
SINEMET 10-100................. 34
SINEMET 25-100................. 34
SINEMET 25-250................. 34
SINEMET CR....................... 34
SINGULAIR ......................... 88
SIRTURO ............................. 31
SKELAXIN........................... 90
SKELID ................................ 82
SKLICE................................. 66
sod propion/‌inositol/‌aa14/‌urea
........................................... 29
sod/‌pot/‌k cit/‌sod cit/‌cit acid .. 86
sodium chloride 3% .............. 87
sodium chloride for inhalation
........................................... 86
sodium chloride/‌nahco3/‌kcl/‌peg
........................................... 73
sodium fluoride ..................... 56
sodium polystyrene sulfonate 74
sodium thiosulfate/‌sal acid ... 25
SOLARAZE............................ 7
SOLODYN ........................... 14
SOMA ................................... 90
SOMATULINE DEPOT....... 78
SOMAVERT ........................ 78
SONATA .............................. 91
SORIATANE........................ 60
SORILUX ............................. 60
sotalol hcl.............................. 42
SPECTRACEF...................... 11
spinosad ................................ 66
SPIRIVA ............................... 88
spironolact/‌hydrochlorothiazid
........................................... 47
spironolactone....................... 47
SPIRONOLACTONE........... 47
SPORANOX ......................... 26
SPRIX ..................................... 7
SPRYCEL ............................. 16
STALEVO 100 ..................... 35
STALEVO 125 ..................... 35
STALEVO 150 ..................... 35
STALEVO 200 ..................... 35
STALEVO 50 ....................... 35
STALEVO 75 ....................... 35
stannous fluoride................... 56
STARLIX.............................. 23
I-19
stavudine ............................... 36
STAVZOR ............................ 19
STAXYN .............................. 91
STELARA............................. 85
STIMATE ............................. 78
STIVARGA .......................... 16
STRATTERA ....................... 49
streptomycin sulfate .............. 10
STRIANT.............................. 75
STRIBILD............................. 37
STROMECTOL.................... 33
SUBLIMAZE.......................... 5
SUBOXONE........................... 8
SUBSYS ................................. 5
SUCLEAR ............................ 74
SUCRAID ............................. 66
sucralfate............................... 71
SUCRALFATE..................... 72
SULAR ................................. 45
sulfacet sod/‌sulfur/‌witch haz. 57
sulfacetamd/‌sulfr/‌sknclnsr10 57
SULFACETAMIDE ............. 13
SULFACETAMIDE SOD
MONOHYDRATE ........... 13
sulfacetamide sod/‌sulfur/‌urea60
sulfacetamide sodium 57, 61, 68
sulfacetamide sodium/‌sulfur 57,
58
sulfacetamide sodium/‌urea ... 57
sulfacetamide/‌prednisolone sp
........................................... 68
sulfacetm na/‌avobenzone/‌sulfur
........................................... 58
sulfadiazine ........................... 13
SULFADIAZINE.................. 14
SULFADIAZINE SODIUM. 13
SULFAMETHOXAZOLE.... 14
sulfamethoxazole/‌trimethoprim
........................................... 13
SULFAMYLON ................... 62
sulfasalazine.......................... 13
SULFASALAZINE .............. 14
SULFISOXAZOLE .............. 14
sulindac ................................... 6
SULINDAC ............................ 7
sumatriptan ........................... 30
sumatriptan succinate ........... 30
SUMAVEL DOSEPRO ........ 31
SUMAXIN............................ 60
SUMAXIN TS ...................... 60
SUPRAX............................... 11
SUPREP................................ 74
SURMONTIL ....................... 22
SUSTIVA.............................. 36
SUTENT ............................... 16
SUTTAR-2............................ 55
SUTTAR-SF ......................... 55
SYLATRON 4-PACK .......... 37
SYMAX ................................ 73
SYMAX DUOTAB .............. 17
SYMAX-SL .......................... 73
SYMAX-SR.......................... 17
SYMBICORT ....................... 87
SYMBYAX .......................... 22
SYMLIN ............................... 23
SYMLINPEN 120................. 23
SYMLINPEN 60................... 23
SYNALAR............................ 65
SYNALGOS-DC .................... 5
SYNAREL ............................ 84
SYNERA ................................ 8
SYNTHROID ....................... 80
SYPRINE.............................. 75
syring w-ndl,disp,insul,0.3ml 66
syring w-ndl,disp,insul,0.5ml 66
syringe & needle,insulin,1 ml 66
TABLOID ............................. 16
TACLONEX ......................... 60
tacrolimus ............................. 80
TACROLIMUS .................... 84
TAFINLAR........................... 16
TAGAMET ........................... 72
TALWIN................................. 5
TAMBOCOR........................ 42
TAMIFLU............................. 37
tamoxifen citrate ................... 15
TAMOXIFEN CITRATE ..... 16
tamsulosin hcl ....................... 91
TAPAZOLE.......................... 80
TARCEVA............................ 16
TARGRETIN.................. 16, 65
TARKA................................. 41
TASIGNA ............................. 16
TASMAR.............................. 34
TAZORAC............................ 65
TECFIDERA......................... 85
TEFLARO............................. 11
TEGRETOL.......................... 19
TEGRETOL XR ................... 18
TEKAMLO ........................... 47
TEKTURNA ......................... 47
TEKTURNA HCT ................ 47
temazepam............................... 9
TEMODAR........................... 16
TEMOVATE......................... 65
TENCON ................................ 5
TENEX ................................. 40
TENORETIC 100 ................. 43
TENORETIC 50 ................... 43
TENORMIN ......................... 43
TERAK ................................. 68
TERAZOL 3 ......................... 29
TERAZOL 7 ......................... 29
terazosin hcl .......................... 91
terbinafine hcl ....................... 25
TERBINAFINE HCL ........... 26
terbutaline sulfate ................. 88
terconazole............................ 29
TERSI FOAM....................... 62
TESSALON .......................... 55
TESSALON PERLE............. 55
TESTIM ................................ 75
TESTOSTERONE ................ 75
testosterone cypionate........... 75
TESTOSTERONE
CYPIONATE.................... 75
testosterone enanthate .......... 75
TESTOSTERONE
ENANTHATE .................. 75
TESTRED ............................. 75
TETRACYCLINE ................ 14
tetracycline hcl...................... 14
I-20
TETRACYCLINE HCL ....... 14
TETRIX ................................ 66
TEVETEN............................. 40
TEVETEN HCT.................... 40
THALOMID ......................... 85
THEO-24............................... 88
theophylline anhydrous......... 88
THEOPHYLLINE
ANHYDROUS ................. 89
THERMAZENE ................... 61
THIOLA................................ 84
thioridazine hcl ..................... 35
THIORIDAZINE
thiothixene............................. 35
THYROID............................. 80
thyroid,pork........................... 80
THYROLAR-1 ..................... 80
THYROLAR-1/‌2 .................. 80
THYROLAR-1/‌4 .................. 80
THYROLAR-2 ..................... 80
THYROLAR-3 ..................... 80
tiagabine hcl.......................... 18
TIAZAC................................ 43
ticlopidine hcl........................ 39
TIGAN .................................. 32
TIKOSYN ............................. 42
TIMENTIN ........................... 13
timolol maleate................ 42, 85
TIMOLOL MALEATE ........ 43
TIMOPTIC............................ 86
TIMOPTIC-XE ..................... 86
TINDAMAX......................... 34
tinidazole............................... 33
TIROSINT ............................ 80
TIS-U-SOL ........................... 82
tizanidine hcl......................... 89
TIZANIDINE HCL............... 90
TOBI ..................................... 10
TOBI PODHALER............... 10
TOBRADEX......................... 68
TOBRADEX ST ................... 68
tobramycin ............................ 68
TOBRAMYCIN...................... 9
tobramycin sulfate................. 10
TOBRAMYCIN SULFATE ... 9
tobramycin/‌dexamethasone... 68
TOBREX............................... 68
TOFRANIL........................... 22
TOFRANIL-PM.................... 22
tolazamide ............................. 24
tolbutamide ........................... 24
tolmetin sodium....................... 6
tolterodine tartrate................ 74
TOPAMAX........................... 19
TOPICORT ........................... 65
topiramate ............................. 18
TOPIRAMATE..................... 19
topotecan hcl......................... 16
TOPROL XL......................... 43
TORISEL .............................. 16
torsemide............................... 45
TOVIAZ................................ 74
TRACLEER.......................... 92
TRADJENTA ....................... 23
tramadol hcl ............................ 2
TRAMADOL HCL................. 5
tramadol hcl/‌acetaminophen .. 2
TRANDATE ......................... 43
trandolapril ........................... 41
tranexamic acid..................... 39
TRANSDERM-SCOP .......... 32
TRANXENE T-TAB .............. 9
tranylcypromine sulfate ........ 20
TRAVATAN Z ..................... 85
travoprost (benzalkonium) .... 85
trazodone hcl......................... 20
TRAZODONE HCL ............. 22
TRECATOR ......................... 31
TRELSTAR .......................... 16
TRENTAL ............................ 39
tretinoin........................... 15, 65
tretinoin microspheres .......... 65
tretinoin/‌emollient................. 65
TRETIN-X ............................ 65
TREXALL ............................ 15
TREXIMET .......................... 31
triacetin ................................. 26
TRIAMCINOLONE ............. 78
triamcinolone acetonide. 56, 63,
87
TRIAMCINOLONE
ACETONIDE.................... 78
triamterene/‌hydrochlorothiazid
........................................... 45
triazolam ................................. 9
TRIBENZOR ........................ 40
TRICOR................................ 46
TRIDERM............................. 65
TRIDESILON ....................... 65
trifluoperazine hcl................. 35
trifluridine ............................. 68
TRIFLURIDINE ................... 68
TRIGLIDE ............................ 47
trihexyphenidyl hcl................ 34
TRILEPTAL ......................... 19
TRILIPIX.............................. 47
trimethobenzamide hcl .......... 32
TRIMETHOBENZAMIDE
HCL................................... 33
trimethobenzamide hcl/‌b-caine
........................................... 32
trimethoprim ......................... 10
TRIMETHOPRIM ................ 10
trimipramine maleate............ 20
TRIMIPRAMINE MALEATE
........................................... 22
TRI-NORINYL..................... 51
tripelennamine hcl ................ 27
TRIPLE ANTIBIOTIC ......... 68
TRIP-PSE.............................. 29
triprolidine hcl ...................... 27
TRIPROLIDINE HCL .......... 29
TRIZIVIR ............................. 36
tropicamide ........................... 70
trospium chloride .................. 74
TRUSOPT............................. 86
TRUVADA ........................... 36
trypsin/‌balsam peru/‌castor oil
..................................... 57, 60
TUDORZA PRESSAIR........ 89
TUSNEL C............................ 55
I-21
TUSNEL PEDIATRIC ......... 55
TUSNEL-DM PEDIATRIC.. 55
TUSSI-12D ........................... 55
TUSSICAPS ......................... 55
TUSSIGON........................... 55
TUSSIONEX ........................ 55
TUSSI-PRES ........................ 55
TUSSI-PRES PEDIATRIC... 55
TWYNSTA ........................... 40
TYGACIL ............................. 14
TYKERB............................... 16
TYLENOL-CODEINE NO.3 . 5
TYLENOL-CODEINE NO.4 . 5
TYLOX ................................... 5
TYPHIM VI .......................... 81
TYSABRI ............................. 81
TYVASO .............................. 92
TYZEKA............................... 38
TYZINE ................................ 70
ULESFIA .............................. 83
ULORIC................................ 84
ULTRACET............................ 5
ULTRAM................................ 5
ULTRAM ER.......................... 5
ULTRAVATE....................... 65
ULTRAVATE PAC.............. 65
ULTRESA............................. 67
UMECTA.............................. 60
UMECTA PD ....................... 60
UNIRETIC............................ 41
UNITHROID ........................ 80
UNIVASC............................. 41
URAMAXIN......................... 60
URAMAXIN GT .................. 60
urea ....................................... 57
urea/‌lactic ac/‌zn undecylenate
........................................... 57
urea/‌lactic acid/‌salicyl acid.. 58
URECHOLINE ..................... 84
URELLE ............................... 10
URIBEL ................................ 10
URIN D.S.............................. 10
UROCIT-K ........................... 87
UROQID-ACID NO.2 .......... 10
UROXATRAL...................... 91
URSO.................................... 73
URSO FORTE ...................... 73
ursodiol ................................. 73
URSODIOL .......................... 73
URYL.................................... 10
UTA ...................................... 11
VAGIFEM ............................ 76
valacyclovir hcl..................... 37
VALCYTE............................ 38
VALIUM................................. 9
valproate sodium................... 18
VALPROATE SODIUM ...... 19
valproic acid ......................... 18
VALPROIC ACID................ 19
valsartan/‌hydrochlorothiazide
........................................... 40
VALTREX............................ 38
VANACOF ........................... 55
VANACOF CD..................... 55
VANACOF DX .................... 55
VANCOCIN HCL ................ 11
vancomycin hcl...................... 10
VANCOMYCIN HCL .......... 11
VANDAZOLE...................... 29
VANOS................................. 65
VANOXIDE-HC................... 60
VASERETIC......................... 41
VASOTEC ............................ 41
VAZOTAN ........................... 55
VECTICAL........................... 60
VELTIN ................................ 62
VENELEX ............................ 60
venlafaxine hcl ...................... 20
VENLAFAXINE HCL ER ... 20
VENTAVIS........................... 92
VENTOLIN .......................... 88
VENTOLIN HFA ................. 88
VERAMYST ........................ 87
verapamil hcl ........................ 43
VERAPAMIL HCL .............. 43
VERDESO ............................ 65
VEREGEN............................ 60
VERELAN............................ 43
VERELAN PM ..................... 43
VERIPRED 20 ...................... 78
VESICARE ........................... 74
VEXOL ................................. 70
VFEND ................................. 26
VIAGRA ............................... 91
VIBATIV .............................. 11
VIBRAMYCIN..................... 14
VICOPROFEN ....................... 5
VICTOZA 3-PAK................. 23
VICTRELIS .......................... 37
VIDEX .................................. 36
VIDEX EC ............................ 37
VIGAMOX ........................... 68
VIIBRYD.............................. 22
VIMOVO ................................ 7
VIMPAT ............................... 18
VIOKACE............................. 67
VIRACEPT ........................... 36
VIRAMUNE ......................... 37
VIRAMUNE XR .................. 36
VIRASAL ............................. 60
VIREAD ............................... 36
VIROPTIC ............................ 69
VISTARIL ............................ 84
VITUZ................................... 53
VIVACTIL............................ 22
VIVELLE-DOT .................... 76
VIVITROL.............................. 8
VOLTAREN ........................... 7
VOLTAREN-XR .................... 7
VORAXAZE......................... 85
voriconazole.......................... 25
VOSOL ................................. 69
VOSOL HC........................... 69
VOSPIRE ER........................ 89
VOTRIENT........................... 16
VPRIV .................................. 67
VUSION ............................... 26
VYTORIN............................. 47
VYVANSE ........................... 49
warfarin sodium .................... 38
WARFARIN SODIUM ........ 38
WELCHOL ........................... 47
I-22
WELLBUTRIN..................... 22
WELLBUTRIN SR............... 22
WELLBUTRIN XL .............. 22
WESTCORT ......................... 65
XALATAN ........................... 86
XALKORI............................. 16
XANAX .................................. 9
XANAX XR............................ 9
XARELTO............................ 38
XCLAIR................................ 84
XELJANZ ............................. 85
XELODA .............................. 17
XENADERM........................ 60
XENAZINE .......................... 49
XERAC AC .......................... 58
XERESE ............................... 60
XEROFORM PETROLATUM
DRESSING ....................... 66
XIFAXAN............................. 11
XODOL 10-300 ...................... 5
XODOL 5-300 ........................ 5
XODOL 7.5-300 ..................... 5
XOLEGEL ............................ 26
XOLOX................................... 5
XOPENEX............................ 89
XOPENEX HFA................... 89
XTANDI ............................... 17
X-VIATE .............................. 60
XYREM ................................ 91
XYZAL ................................. 29
YASMIN 28.......................... 51
YAZ ...................................... 51
YERVOY.............................. 17
YODOXIN............................ 34
yohimbine hcl ........................ 91
zafirlukast.............................. 88
zaleplon ................................. 90
ZAMICET............................... 5
ZANAFLEX ......................... 90
ZANOSAR............................ 17
ZANTAC .............................. 72
ZANTAC 25 ......................... 72
ZARONTIN .......................... 19
ZAROXOLYN...................... 45
ZAVESCA ............................ 67
Z-COF I................................. 55
Z-DEX................................... 55
ZEBETA ............................... 43
ZEBUTAL .............................. 5
ZEGERID ............................. 72
ZEGERID OTC .................... 71
ZELAPAR............................. 35
ZELBORAF.......................... 17
ZEMPLAR............................ 82
ZENPEP................................ 66
ZENZEDI.............................. 49
ZERIT ................................... 37
ZESTORETIC....................... 41
ZESTRIL............................... 41
ZETIA ................................... 46
ZETONNA............................ 87
ZGESIC................................... 5
ZIAC ..................................... 43
ZIAGEN.......................... 36, 37
ZIANA .................................. 62
zidovudine ............................. 36
ZIOPTAN ............................. 86
ziprasidone hcl ...................... 35
ZIPSOR................................... 7
ZIRGAN ............................... 68
ZITHROMAX....................... 12
ZITHROMAX TRI-PAK...... 12
ZMAX................................... 12
ZOCOR ................................. 47
ZODRYL AC 25................... 55
ZODRYL AC 30................... 55
ZODRYL AC 35................... 55
ZODRYL AC 40................... 55
ZODRYL AC 50................... 55
ZODRYL AC 60................... 55
ZODRYL AC 80................... 55
ZODRYL DAC 50................ 55
ZODRYL DAC 60................ 55
ZODRYL DAC 80................ 55
ZODRYL DEC 25 ................ 56
ZODRYL DEC 30 ................ 56
ZODRYL DEC 35 ................ 56
ZODRYL DEC 40 ................ 56
ZODRYL DEC 50 ................ 56
ZODRYL DEC 60 ................ 56
ZODRYL DEC 80 ................ 56
ZOFRAN .............................. 33
ZOFRAN ODT ..................... 33
ZOLINZA ............................. 16
zolmitriptan ........................... 30
ZOLOFT ............................... 22
zolpidem tartrate................... 90
ZOLPIMIST.......................... 91
ZOMETA.............................. 82
ZOMIG ................................. 31
ZOMIG ZMT ........................ 31
ZONALON ........................... 60
ZONATUSS.......................... 56
ZONEGRAN......................... 19
zonisamide............................. 18
ZORTRESS .......................... 81
ZOSYN ................................. 13
ZOTEX-C ............................. 56
ZOTEX-D ............................. 56
ZOTEX-EX........................... 56
ZOTEX-PE ........................... 29
ZOVIRAX....................... 38, 60
Z-TUSS AC .......................... 56
ZUPLENZ............................. 33
ZUTRIPRO ........................... 56
ZYBAN................................... 8
ZYCLARA............................ 60
ZYDONE ................................ 5
ZYFLO.................................. 88
ZYFLO CR ........................... 88
ZYLET.................................. 69
ZYLOPRIM .......................... 84
ZYMAXID............................ 69
ZYMINE ............................... 29
ZYMINE DXR...................... 29
ZYMINE XR ........................ 29
ZYMINE-D........................... 29
ZYPRAM.............................. 65
ZYPREXA ............................ 36
ZYPREXA ZYDIS ............... 36
ZYRTEC ............................... 27
ZYRTEC-D........................... 27
I-23
ZYTIGA................................ 17
ZYVOX................................. 11
I-24

REVISED March 5 TIER Formulary doc

Transcription

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