PMD 2011 Comprehensive Formulary Publication Document

Comments

Transcription

PMD 2011 Comprehensive Formulary Publication Document
The symbol LTD next to a drug name indicates that the drug has been noted as
being restricted to certain pharmacies by the Food and Drug Administration. These
drugs can only be obtained at specialty designated pharmacies able to appropriately
handle the drugs.
The symbol PA in the Restrictions column indicates that prior authorization may
apply.
The symbol QLL in the Restrictions column indicates that quantities dispensed may
be limited.
The symbol ST in the Restrictions column indicates that step therapy may apply.
General Drug Table
Drug
Tier
Restrictions
ANESTHETICS
LOCAL ANESTHETICS
lidocaine hcl injection
1
TOPICAL ANESTHETICS
anestacon
lidocaine hcl cream, -jel, -lotion, -ointment, solution non-oral
lidocaine hcl viscous
lidocaine-prilocaine
LIDODERM
pre-attached lta kit
SYNERA
1
1
1
1
3
1
3
PA, QLL (93/31)
ANTIINFECTIVES
AMEBICIDES
paromomycin sulfate
YODOXIN
1
2
AMINOGLYCOSIDES
amikacin sulfate injection
1
Page 1 of 117
Drug
GENTAMICIN 60 MG/NS 100 ML PB, -ISOTON
GENTAMICIN 60 MG/100 ML, -80 MG/NS 100 ML
PB, -ISOTON GENTAMICIN 80 MG/100 ML, -ISO
GENTAMICIN 120 MG/100 ML
Tier
Restrictions
3
gentamicin 90 mg/ns 100 ml pb, -100 mg/ns 100 1
ml, -iso gentamicin 100 mg/100 ml, -60 mg/ns
50 ml pb, -isoton gentamicin 60 mg/50 ml, -70
mg/ns 50 ml pb, -80 mg/ns 50 ml pb, -isoton
gentamicin 80 mg/50 ml
gentamicin sulfate injection
1
kanamycin sulfate injection
1
NEO-FRADIN
neomycin sulfate tablet
TOBI
tobramycin sulfate in ns
tobramycin sulfate injection
2
1
4
1
1
PA, QLL (280/28)
ANTHELMINTICS
ALBENZA
BILTRICIDE
mebendazole tablet chewable
STROMECTOL
2
2
1
2
ANTIINFECTIVES SPECIALIZED INDICATIONS
DAPSONE TABLET
FLAGYL ER
metro iv
metronidazole capsule, -injection, -tablet
2
3
1
1
ANTIRETROVIRALS AND PROTEASE INH
APTIVUS
ATRIPLA
COMBIVIR
CRIXIVAN
didanosine
EDURANT
EMTRIVA
4
4
4
2
1
3
2
Page 2 of 117
Drug
EPIVIR
EPZICOM
FUZEON
INCIVEK
INTELENCE
INVIRASE
ISENTRESS
KALETRA 100-25 MG TABLET
KALETRA SOLUTION, -200-50 MG TABLET
LEXIVA SUSPENSION ORAL
LEXIVA TABLET
NORVIR CAPSULE, -TABLET
NORVIR SOLUTION
PREZISTA 400 MG TABLET, -600 MG TABLET
PREZISTA 75 MG TABLET, -150 MG TABLET
RESCRIPTOR
RETROVIR INJECTION
REYATAZ
SELZENTRY
stavudine
SUSTIVA
TRIZIVIR
TRUVADA
VICTRELIS
VIDEX
VIRACEPT POWDER
VIRACEPT TABLET
VIRAMUNE
VIRAMUNE XR
VIREAD
ZIAGEN
zidovudine
Tier
2
4
4
4
4
4
4
3
4
3
4
3
4
4
2
2
3
4
4
1
2
4
4
4
3
3
4
3
3
2
2
1
Restrictions
PA, QLL (186/31)
PA, QLL (372/31)
ANTITUBERCULOSIS DRUGS
CAPASTAT SULFATE
ethambutol hcl
isonarif
isoniazid injection, -syrup, -tablet
MYCOBUTIN
4
1
1
1
3
Page 3 of 117
Drug
PASER
PRIFTIN
pyrazinamide
RIFAMATE
rifampin capsule
rifampin injection
RIFATER
SEROMYCIN
STREPTOMYCIN SULFATE INJECTION
TRECATOR
Tier
Restrictions
3
3
1
3
1
4
3
3
2
3
CEPHALOSPORINS
CEDAX
3
1
1
1
1
cefaclor
cefaclor er
cefadroxil
cefazolin 20 gm bulk vial, -500 mg vial, -1 gm
add-van vial, -1 gm vial, -1 gm-d5w bag, -10 gm
vial
cefazolin sod 100 gm bulk bag, -sod 300 gm bulk 1
bag
cefdinir
1
CEFDITOREN PIVOXIL 400 MG TAB
cefepime hcl
cefotaxime sodium
cefotetan
cefoxitin
cefoxitin sodium
cefpodoxime proxetil
cefprozil
ceftazidime 500 mg vial
ceftriaxone
cefuroxime
cefuroxime axetil
CEFUROXIME SOD 75 GM BULK BAG
cefuroxime sod 750 mg vial, -sod 1.5 gm vial, sod 7.5 gm vial
cephalexin
FORTAZ 500 MG VIAL
3
1
1
1
1
1
1
1
1
1
1
1
3
1
1
3
Page 4 of 117
Drug
FORTAZ IN ISO-OSMOTIC DEXTROSE
KEFLEX 750 MG CAPSULE
SPECTRACEF
SUPRAX
TEFLARO
Tier
Restrictions
3
3
3
3
3
CHLORAMPHENICOLS
chloramphenicol sod succinate
1
CLINDAMYCINS
CLEOCIN HCL 75 MG CAPSULE
CLEOCIN PALMITATE
CLEOCIN PHOSPHATE IN D5W
clindamycin hcl capsule
clindamycin palmitate hcl
clindamycin phosphate injection
3
2
3
1
1
1
ERYTHROMYCINS
ERYPED 200
ERYPED 400
ERY-TAB
ERYTHROCIN LACTOBIONATE
erythrocin stearate
erythromycin capsule enteric coated, -tablet
erythromycin ethylsuccinate tablet
PCE
3
3
3
3
1
1
1
3
ORAL ANTIFUNGAL DRUGS
ANCOBON
clotrimazole troche
fluconazole suspension, -tablet
GRIFULVIN V
griseofulvin suspension oral
GRIS-PEG
itraconazole capsule
ketoconazole tablet
4
1
1
2
1
2
1
1
PA, QLL (366/90)
Page 5 of 117
Drug
NOXAFIL
nystatin 150,000,000 units pwd
nystatin 50,000,000 units pwd, -500,000,000
units pwd, -suspension oral, -500,000 unit oral
tab
terbinafine hcl tablet
VFEND
voriconazole
Tier
4
3
1
Restrictions
PA
1
4
1
OTHER ANTIINFECTIVE DRUGS
ALINIA
AZACTAM 1 GM VIAL
AZACTAM-ISO-OSMOT 1 GM/50 ML
AZACTAM-ISO-OSMOT 2 GM/50 ML
aztreonam
baciim
bacitracin injection
CAYSTON
colistimethate 150 mg vial
CUBICIN
DIFICID
DORIBAX 500 MG VIAL
INVANZ
LINCOCIN
MEPRON
meropenem
NEBUPENT
polymyxin b sulfate injection
PRIMAXIN 250 MG VIAL
PRIMAXIN 500 MG VIAL
PRIMAXIN I.M.
SYNERCID
TYGACIL
VANCOCIN HCL
VANCOMYCIN
vancomycin 1 gm vial, -10 gm vial
vancomycin 500 mg a/v vial, -500 mg vial, -750
mg vial, -1 gm add-van vial, -5 gm vial
VANCOMYCIN HCL 1G/200 ML BAG
2
4
3
4
1
1
1
4
4
4
4
4
2
3
4
1
2
1
3
4
4
4
4
4
4
1
1
QLL (84 vials/28), LTD
PA
QLL (20/10), ST
PA
PA
4
Page 6 of 117
Drug
VIBATIV
XIFAXAN 200 MG TABLET
XIFAXAN 550 MG TABLET
ZYVOX
Tier
4
3
3
4
Restrictions
QLL (93/31)
PA, QLL (62/31)
OTHER ANTIVIRAL DRUGS
acyclovir capsule, -suspension oral, -tablet
acyclovir sodium
amantadine
BARACLUDE SOLUTION
BARACLUDE TABLET
COPEGUS
DENAVIR
EPIVIR HBV
famciclovir
foscarnet sodium
ganciclovir
ganciclovir sodium
HEPSERA
REBETOL CAPSULE
REBETOL SOLUTION
RELENZA
RIBAPAK
RIBASPHERE 400 MG TABLET, -600 MG TABLET
ribasphere capsule, -200 mg tablet
RIBATAB 400-400 MG DOSEPACK, -600-600 MG
DOSEPACK
RIBAVIRIN 400 MG TABLET, -600 MG TABLET
ribavirin capsule, -200 mg tablet
rimantadine hcl
TAMIFLU 30 MG GELCAP, -45 MG GELCAP, SUSPENSION
TAMIFLU 75 MG GELCAP
TYZEKA
valacyclovir
VALCYTE
VIRAZOLE
VISTIDE
1
1
1
3
4
4
2
2
1
1
4
1
4
4
4
2
QLL (186/31)
QLL (186/31)
QLL (120
inhalations/365)
4
4
1
4
4
1
1
2
2
3
1
4
4
4
QLL (56/365)
Page 7 of 117
Drug
ZOVIRAX CREAM, -OINTMENT
Tier
Restrictions
2
OTHER MACROLIDES
azithromycin injection, -packet, -suspension, tablet
clarithromycin er
clarithromycin suspension, -tablet
1
1
1
OTHER TOPICAL ANTIFUNGALS
ciclopirox cream, -gel, -solution non-oral, suspension topical
clotrimazole cream, -solution non-oral
econazole nitrate cream
ketoconazole cream, -shampoo
NAFTIN
nyamyc
nystatin cream, -ointment, -100,000 unit/gm
powd
nystop
OXISTAT
pedi-dri
1
1
1
1
3
1
1
1
3
1
PARENTERAL ANTIFUNGALS
ABELCET
AMBISOME
AMPHOTEC
amphotericin b injection
CANCIDAS
ERAXIS (WATER DILUENT)
fluconazole in dextrose
fluconazole in saline
MYCAMINE
VFEND IV
4
4
3
1
4
3
1
1
4
4
PENICILLINS
amox tr-potassium clavulanate
1
Page 8 of 117
Drug
amoxicillin
amoxicillin-clavulanate er
ampicillin sodium
ampicillin trihydrate
ampicillin-sulbactam
BICILLIN C-R
BICILLIN L-A
dicloxacillin sodium
NAFCILLIN 1 GM/ 50 ML INJ
nafcillin 2 gm/ 100 ml inj
nafcillin sodium
OXACILLIN
oxacillin 1 gm add-vantage vl, -1 gm vial
OXACILLIN 10 GM VIAL
oxacillin 2 gm add-vantage vl, -2 gm vial
penicillin g potassium
penicillin g procaine
penicillin g sodium
PENICILLIN GK-ISO-OSM DEXTROSE
penicillin v potassium
PFIZERPEN
piperacillin
piperacillin-tazobactam
TIMENTIN
UNASYN 1.5 GM ADD-VANTAGE VL, -1.5 GM
PIGGYBACK BOTTLE, -3 GM ADD-VANTAGE
VIAL, -3 GM PIGGYBACK BOTTLE
ZOSYN 2.25 GRAM VIAL, -2.25 GM GALAXY BAG,
-2.25 GM PRE-MIX BAG, -3.375 GM GALAXY
BAG, -3.375 GM PRE MIX-BAG, -4.5 GM GALAXY
BAG, -4.5 GM PRE-MIX BAG, -4.5 GRAM VIAL, 40.5 GRAM BULK VIAL
Tier
Restrictions
1
1
1
1
1
3
3
1
4
4
4
4
1
4
4
1
1
1
2
1
3
1
1
3
3
3
PLASMODICIDES
atovaquone-proguanil hcl
chloroquine phosphate tablet
COARTEM
DARAPRIM
hydroxychloroquine sulfate tablet
1
1
2
2
1
Page 9 of 117
Drug
MALARONE
mefloquine hcl
PRIMAQUINE
Tier
Restrictions
2
1
2
QUINOLONES
AVELOX
AVELOX ABC PACK
AVELOX IV
ciprofloxacin
ciprofloxacin er 1,000 mg tab
ciprofloxacin er 500 mg tablet
ciprofloxacin hcl tablet
ciprofloxacin-d5w
FACTIVE
LEVAQUIN
levofloxacin injection, -solution, -tablet
levofloxacin-d5w
NOROXIN
ofloxacin tablet
3
3
3
1
1
1
1
1
3
3
1
1
3
1
QLL (14/14)
QLL (28/31)
QLL (7/30)
SULFONAMIDES
erythromycin-sulfisoxazole
sulfadiazine tablet
sulfamethoxazole-trimethoprim
1
1
1
TETRACYCLINES
demeclocycline hcl
1
doxycycline
1
doxycycline hyclate capsule, -hyc dr 75 mg cap, - 1
injection, -100 mg tab
doxycycline mono 50 mg cap, -mono 100 mg
1
cap, -tablet
minocycline hcl capsule, -tablet
1
tetracycline hcl capsule
1
VIBRAMYCIN SUSPENSION, -SYRUP
2
Page 10 of 117
Drug
Tier
TOPICAL ANTIBACTERIAL DRUGS
BACTROBAN NASAL
CHLORHEXIDINE GLUC 20% SOLN
gentamicin sulfate cream, -0.1% ointment
mupirocin ointment
silver sulfadiazine cream
ssd
ssd af
thermazene
Restrictions
3
3
1
1
1
1
1
1
TOPICAL ANTIFUNGAL-CORTICOSTEROID COMB.
clotrimazole-betamethasone
nystatin-triamcinolone
1
1
URINARY ANTIINFECTIVES
FURADANTIN
MACRODANTIN 25 MG CAPSULE
methenamine hippurate
methenamine mandelate tablet
MONUROL
nitrofurantoin macrocrystal capsule
nitrofurantoin mono-macro
nitrofurantoin suspension oral
trimethoprim tablet
uretron d-s
urogesic-blue
UTIRA-C
2
2
1
1
2
1
1
1
1
1
1
2
VAGINAL ANTIFUNGALS
miconazole 3 suppository vaginal
nystatin vaginal tablet
terconazole
ZAZOLE SUPPOSITORY VAGINAL
1
1
1
2
Page 11 of 117
Drug
Tier
Restrictions
ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC/IMMUNOSUPPRESSANT
DRUGS
ABRAXANE
adriamycin 10 mg vial, -20 mg vial, -50 mg vial
adriamycin 2 mg/ml vial
adrucil
AFINITOR
ALIMTA
ALKERAN INJECTION
AMEVIVE
amifostine
anagrelide hcl
anastrozole tablet
AROMASIN
ARRANON
AVASTIN
AZASAN
AZATHIOPRINE SODIUM
azathioprine tablet
bicalutamide
BICNU
bleomycin sulfate 15 unit vial
bleomycin sulfate 30 unit vial
BUSULFEX
CAMPATH
CAPRELSA 100 MG TABLET
CAPRELSA 300 MG TABLET
carboplatin 150 mg/15 ml vial
carboplatin 450 mg/45 ml vial, -50 mg/5 ml vial,
-600 mg/60 ml vial, -50 mg vial, -150 mg vial, 450 mg vial
CEENU
CELLCEPT INJECTION
CELLCEPT SUSPENSION RECONSTITUTED ORAL
CIMZIA 200 MG VIAL KIT, -200 MG/ML SYRINGE
KIT
cisplatin
cladribine
CLOLAR
4
1
1
1
4
4
3
4
1
1
1
3
3
4
2
2
1
1
3
4
4
3
4
4
4
1
1
2
3
4
4
PA, QLL (31/31)
PA, QLL (24/365), LTD
PA
PA
PA
PA, QLL (93/31)
PA, QLL (31/31)
PA
PA
PA, QLL (6/28)
1
4
4
Page 12 of 117
Drug
COSMEGEN
cyclophosphamide injection
cyclophosphamide tablet
cyclosporine capsule, -injection, -solution
cyclosporine modified
cyclosporine unit
cytarabine 100 mg vial, -1 gm vial, -2 gm vial
cytarabine 20 mg/ml vial, -100 mg/ml vial, -500
mg vial
dacarbazine 100 mg vial
dacarbazine 200 mg vial
DACOGEN
dactinomycin
daunorubicin hcl
DAUNOXOME
DEPO-PROVERA 400 MG/ML VIAL
dexrazoxane 250 mg vial
dexrazoxane 500 mg vial
docetaxel 80 mg/8 ml vial
DOXIL
Tier
3
1
1
1
1
1
1
1
Restrictions
PA
PA
PA
1
1
4
1
1
3
3
1
1
1
4
1
doxorubicin 10 mg/5 ml vial, -20 mg/10 ml vial, 50 mg/25 ml vial, -10 mg vial, -50 mg vial
doxorubicin 200 mg/100 ml vial
1
DROXIA
ELIGARD 22.5 MG SYRINGE
ELIGARD 30 MG SYRINGE
ELIGARD 45 MG SYRINGE
ELIGARD 7.5 MG SYRINGE
ELITEK
ELLENCE
ELOXATIN
ELSPAR
EMCYT
ENBREL 25 MG KIT, -25 MG/0.5 ML SYRINGE, 50 MG/ML SYRINGE
ENBREL 50 MG/ML SURECLICK SYR
epirubicin 200 mg/100 ml vial, -50 mg vial, -150
mg/75 ml vial, -200 mg vial
epirubicin 50 mg/25 ml vial
ERBITUX
3
3
3
3
3
4
3
3
4
3
4
PA,
PA,
PA,
PA,
QLL
QLL
QLL
QLL
(1/84)
(1/112)
(1/168)
(1/28)
PA, QLL (8/28)
4
1
1
4
Page 13 of 117
Drug
ETHYOL
ETOPOPHOS
etoposide injection
exemestane
FARESTON
FASLODEX
FEMARA
FIRMAGON 2 X 120 MG VIALS
FIRMAGON 80 MG VIAL
floxuridine
FLUDARABINE 50 MG VIAL
fludarabine 50 mg/2 ml vial
fluorouracil injection
flutamide
fudr
gemcitabine hcl
GEMZAR
gengraf
GLEEVEC 100 MG TABLET
GLEEVEC 400 MG TABLET
HALAVEN
HERCEPTIN
HEXALEN
HUMIRA
HYCAMTIN INJECTION
hydroxyurea capsule
IDAMYCIN PFS
idarubicin hcl
ifosfamide
ifosfamide-mesna
IRESSA
irinotecan hcl
IXEMPRA
leflunomide
letrozole
leucovorin calcium injection, -tablet
LEUKERAN
LUPRON DEPOT 45 MG 6MO KIT
LYSODREN
Tier
3
3
1
1
2
4
3
4
3
1
2
1
1
1
1
1
3
1
4
4
4
2
4
4
4
1
3
1
1
1
4
4
4
1
1
1
2
4
4
Restrictions
PA, QLL (2/365)
PA, QLL (4/28)
PA
PA, QLL (93/31)
PA, QLL (62/31)
PA, QLL (5.60
syringes/28)
PA, QLL (31/31), LTD
PA, QLL (1/168)
Page 14 of 117
Drug
MATULANE
MEGACE ES
megestrol acetate suspension oral, -tablet
melphalan hcl
mercaptopurine tablet
MESNEX INJECTION
MESNEX TABLET
methotrexate injection, -tablet
mitomycin injection
mitoxantrone hcl
MUSTARGEN
mycophenolate mofetil
MYFORTIC
NEXAVAR
NILANDRON
NULOJIX
octreotide acet 100 mcg/ml amp, -acet 100
mcg/ml syr, -acet 100 mcg/ml vl, -acet 200
mcg/ml vl, -acet 500 mcg/ml amp, -acet 500
mcg/ml vl, -1,000 mcg/ml vial
octreotide acet 50 mcg/ml amp
octreotide acet 50 mcg/ml syr, -acet 50 mcg/ml
vial
ONCASPAR
ONTAK
ORENCIA 250 MG VIAL
ORTHOCLONE OKT-3
oxaliplatin
paclitaxel 100 mg/16.7 ml vial, -30 mg/5 ml vial
paclitaxel 300 mg/50 ml vial
pentostatin
PHOTOFRIN
PROGRAF INJECTION
RAPAMUNE
REMICADE
REVLIMID
RITUXAN
SANDIMMUNE SOLUTION
SANDOSTATIN
SANDOSTATIN LAR
Tier
4
3
1
1
1
2
4
1
1
1
3
1
2
4
2
4
4
Restrictions
PA
PA
PA
PA
PA, QLL (124/31), LTD
PA
1
3
4
4
4
3
1
1
1
1
3
3
3
4
4
4
2
4
4
PA
PA
PA
PA
PA
PA, QLL (31/31), LTD
PA
PA
PA, QLL (1/28)
Page 15 of 117
Drug
SIMPONI 50 MG/0.5 ML PEN INJEC
SIMPONI 50 MG/0.5 ML SYRINGE
SIMULECT
SOMATULINE DEPOT
SORIATANE 10 MG CAPSULE, -25 MG CAPSULE
SORIATANE CK
SPRYCEL 20 MG TABLET, -50 MG TABLET, -70
MG TABLET
SPRYCEL 80 MG TABLET, -100 MG TABLET, -140
MG TABLET
STELARA 45 MG/0.5 ML SYRINGE, -45 MG/0.5
ML VIAL
STELARA 90 MG/ML SYRINGE
SUTENT
TABLOID
tacrolimus capsule
tamoxifen citrate tablet
TARCEVA 100 MG TABLET, -150 MG TABLET
TARCEVA 25 MG TABLET
TARGRETIN CAPSULE
TARGRETIN GEL
TASIGNA
TAXOTERE 20 MG/0.5 ML VIAL, -80 MG/2 ML
VIAL
THERACYS
THIOTEPA INJECTION
topotecan hcl
TORISEL
TRELSTAR
TRELSTAR
TRELSTAR
TRELSTAR
TRELSTAR
TRELSTAR
11.25 MG SYRINGE
22.5 MG SYRINGE
22.5 MG VIAL
3.75 MG SYRINGE
DEPOT
LA
tretinoin capsule
TRISENOX
TYKERB
TYSABRI
UVADEX
VANDETANIB 100 MG TABLET
Tier
4
4
3
4
4
4
4
Restrictions
PA, QLL (0.50/28)
PA
PA, QLL (1/28)
PA, QLL (62/31)
4
PA, QLL (31/31)
4
PA, QLL (0.50/28)
4
4
3
1
1
4
4
4
4
4
4
PA, QLL (1/28)
PA, QLL (31/31)
3
3
4
4
3
4
4
3
3
3
4
3
4
4
3
4
PA
PA, QLL (31/31)
PA
PA
PA, QLL (124/31)
PA,
PA
PA,
PA,
PA,
PA,
QLL (1/84)
QLL
QLL
QLL
QLL
(1/84)
(1/28)
(1/28)
(1/84)
PA, QLL (186/31)
PA, QLL (15/28), LTD
PA, QLL (93/31), LTD
Page 16 of 117
Drug
VANDETANIB 300 MG TABLET
VANTAS
VECTIBIX 100 MG/5 ML VIAL
VECTIBIX 400 MG/20 ML VIAL
VELCADE
VIDAZA
vinblastine 1 mg/ml vial
vinblastine sulf 10 mg vial
vincristine 1 mg/ml vial
vincristine 2 mg/2 ml vial
vinorelbine 10 mg/ml vial
vinorelbine 50 mg/5 ml vial
VOTRIENT
VUMON
ZANOSAR
ZEVALIN
ZOLADEX
ZOLINZA
ZORTRESS 0.25 MG TABLET
ZORTRESS 0.5 MG TABLET, -0.75 MG TABLET
ZYTIGA
Tier
4
4
4
2
4
4
1
1
1
1
1
1
4
3
3
4
3
4
2
4
4
Restrictions
PA, QLL (31/31), LTD
PA
PA, QLL (124/31)
PA
PA, QLL (124/31)
PA
PA
PA, QLL (124/31)
AUTONOMIC AND CNS MEDICATIONS
ANALGESICS
acetaminophen-tramadol
BUPRENORPHINE 0.3 MG/ML SYRN
butorphanol tartrate injection
nalbuphine hcl injection
poly-650
PRIALT
tramadol hcl tablet
tramadol hcl-acetaminophen
1
2
1
1
1
3
1
1
QLL (248/31)
QLL (40/5)
ANTIDEMENTIA DRUGS
COGNEX
donepezil hcl
EXELON PATCH TRANSDERMAL 24 HOURS
EXELON SOLUTION
galantamine hbr
3
1
2
3
1
Page 17 of 117
Drug
galantamine hydrobromide
NAMENDA
RAZADYNE SOLUTION
rivastigmine
Tier
Restrictions
1
2
3
1
ANTIMANIA DRUGS
lithium
lithium carbonate capsule, -tablet, -tablet
sustained action
1
1
ANTIPARKINSON ANTICHOLINERGIC DRUGS
benztropine mesylate injection, -tablet
COGENTIN
trihexyphenidyl hcl
1
3
1
ANTIPSYCHOTIC DRUGS
ABILIFY
ABILIFY
ABILIFY
ABILIFY
DISCMELT
INJECTION
SOLUTION
TABLET
chlorpromazine hcl injection, -tablet
clozapine
FANAPT TABLET
FANAPT TABLET DOSE PACK
FAZACLO
fluphenazine decanoate
fluphenazine hcl
GEODON CAPSULE
GEODON INJECTION
haloperidol dec 50 mg/ml vial, -dec 100 mg/ml
vial
haloperidol decanoate 100
haloperidol lactate
haloperidol tablet
INVEGA ER 1.5 MG TABLET, -ER 3 MG TABLET, ER 9 MG TABLET
INVEGA ER 6 MG TABLET
3
3
3
3
1
1
3
3
3
1
1
2
2
1
PA, QLL (62/31)
PA
PA, QLL (900/30)
PA, QLL (31/31)
PA, QLL (62/31)
PA
QLL (62/31)
1
1
1
3
PA, QLL (31/31)
3
PA, QLL (62/31)
Page 18 of 117
Drug
INVEGA SUSTENNA 117 MG PREF SY, -156 MG
PREF SY, -234 MG PREF SY
INVEGA SUSTENNA 39 MG PREF SYR, -78 MG
PREF SYR
LATUDA
loxapine
NAVANE 20 MG CAPSULE
ORAP
perphenazine
RISPERDAL CONSTA 12.5 MG SYR, -25 MG SYR
RISPERDAL CONSTA 37.5 MG SYR, -50 MG SYR
risperidone
risperidone
risperidone
risperidone
m-tab
odt
solution
tablet
SAPHRIS
SEROQUEL
SEROQUEL XR 150 MG TABLET, -200 MG
TABLET
SEROQUEL XR 50 MG TABLET, -300 MG TABLET,
-400 MG TABLET
thioridazine hcl
thiothixene
trifluoperazine hcl
ZYPREXA 15 MG TABLET, -20 MG TABLET
ZYPREXA 2.5 MG TABLET, -5 MG TABLET, -7.5
MG TABLET, -10 MG TABLET
ZYPREXA INJECTION
ZYPREXA RELPREVV
ZYPREXA ZYDIS 15 MG TABLET, -20 MG TABLET
ZYPREXA ZYDIS 5 MG TABLET, -10 MG TABLET
Tier
Restrictions
4
PA
3
PA
3
1
2
2
1
3
4
1
1
1
1
3
3
3
PA, QLL (31/31)
3
PA, QLL (62/31)
1
1
1
2
2
QLL (62/31)
QLL (31/31)
2
4
2
2
QLL (62/31)
QLL (31/31)
PA
PA
QLL (62/31)
QLL (62/31)
PA, QLL (62/31)
PA, QLL (93/31)
PA, QLL (31/31)
ANTIVERTIGO AND ANTIEMETIC DRUGS
ALOXI
ANZEMET 100 MG TABLET
ANZEMET 50 MG TABLET
ANZEMET INJECTION
compro
dronabinol 2.5 mg capsule
DRONABINOL 5 MG CAPSULE, -10 MG CAPSULE
4
3
3
3
1
1
4
PA, QLL (14/30), ST
PA, QLL (7/30), ST
PA
PA
Page 19 of 117
EMEND
EMEND
EMEND
EMEND
EMEND
Drug
125 MG CAPSULE
40 MG CAPSULE
80 MG CAPSULE
INJECTION
TRIFOLD PACK
granisetron hcl 0.1 mg/ml vial
granisetron hcl 1 mg/ml vial, -4 mg/4 ml vial
granisetron hcl tablet
granisol
meclizine hcl tablet
ondansetron hcl 24 mg tablet
ondansetron hcl 4 mg tablet, -8 mg tablet
ondansetron hcl in dextrose
ondansetron hcl injection
ondansetron hcl solution
ondansetron in sodium chloride
ondansetron odt
phenadoz
prochlorperazine edisylate
prochlorperazine maleate suppository rectal, tablet
promethazine hcl suppository rectal
promethegan
SANCUSO
TRANSDERM-SCOP
trimethobenzamide hcl capsule, -injection
Tier
3
3
3
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
1
Restrictions
PA, QLL (2/31)
PA, QLL (1/30)
PA, QLL (4/30)
PA
PA, QLL (6/28)
QLL (140/30)
QLL (14/30)
PA, QLL (31/31), ST
PA, QLL (310 ml/31), ST
PA, QLL (31/31)
PA, QLL (93/31)
PA, QLL (930 ml/31)
PA, QLL (93/31)
QLL (4/28), ST
ANXIOLYTICS
buspirone hcl tablet
meprobamate
1
1
CARBAMAZEPINES
carbamazepine capsule sustained action, suspension oral, -tablet, -tablet chewable
carbamazepine xr
CARBATROL
epitol
EQUETRO
1
1
3
1
3
Page 20 of 117
oxcarbazepine
Drug
TEGRETOL XR 100 MG TABLET
TRILEPTAL SUSPENSION
Tier
Restrictions
1
2
3
CLASS II NARCOTICS
ABSTRAL
belladonna-opium
codeine phosphate injection
codeine sulfate
DEMEROL 75 MG/ML SYRINGE
diskets
endocet
endodan
fentanyl 100 mcg/hr patch
fentanyl 12 mcg/hr patch, -25 mcg/hr patch, -50
mcg/hr patch, -75 mcg/hr patch
fentanyl citrate injection
fentanyl citrate lozenge
hydromorphone hcl 1 mg/ml amp, -1 mg/ml
syringe, -2 mg/ml syringe, -2 mg/ml vial, -2
mg/ml amp, -2 mg/ml vl, -4 mg/ml syrin, -10
mg/ml vial, -50 mg/5 ml vial, -500 mg/50 ml via,
-10 mg/ml amp, -suppository rectal, -tablet
levorphanol tartrate tablet
meperidine hcl injection, -solution, -tablet
meperitab
methadone hcl injection, -solution, -tablet, tablet soluble
methadone intensol
methadose
morphine sulfate in dextrose
morphine sulfate injection, -solution, suppository rectal, -tablet
morphine sulfate tablet sustained action
ONSOLIS
OPANA ER
oxycodone concentrate
oxycodone hcl
oxycodone hcl-acetaminophen
oxycodone hcl-aspirin
4
1
1
1
2
1
1
1
1
1
1
4
1
PA, QLL (124/31)
QLL (30/30)
QLL (10/30)
PA, QLL (120/30)
1
1
1
1
1
1
1
1
1
4
2
1
1
1
1
QLL (93/31)
PA, QLL (124/31), LTD
QLL (62/31)
Page 21 of 117
Drug
oxycodone hcl-ibuprofen
oxycodone-acetaminophen
oxycodone-aspirin
oxymorphone hcl tablet
oxymorphone hcl tablet sustained release 12hr
roxicet 5-325 tablet
ROXICET SOLUTION
ROXICODONE INTENSOL
ROXICODONE SOLUTION
ROXICODONE TABLET
sublimaze
Tier
1
1
1
1
1
1
3
2
2
3
1
Restrictions
QLL (124/31)
QLL (62/31)
CLASS III NARCOTICS
acetaminoph-caff-dihydrocodein
acetaminophen-codeine
buprenorphine 2 mg tablet sl
buprenorphine 8 mg tablet sl
co-gesic
hydrocodone bit-ibuprofen
hydrocodone-acetaminophen solution, hydrocodon-acetaminoph 2.5-500, -hydrocodonacetaminophen 5-325, -hydrocodonacetaminophen 5-500, -hydrocodon-acetaminoph
7.5-325, -hydrocodon-acetaminoph 7.5-750, hydrocodon-acetaminophn 10-650, -hydrocodonacetaminophn 10-325, -hydrocodon-acetaminoph
7.5-500, -hydrocodon-acetaminophn 10-500, hydrocodon-acetaminoph 7.5-650, -hydrocodonacetaminophn 10-660, -hydrocodonacetaminophn 10-750
1
1
1
1
1
1
1
SUBOXONE 2 MG-0.5 MG SL FILM, -2 MG-0.5 MG 2
TABLET SL
SUBOXONE 8 MG-2 MG SL FILM, -8 MG-2 MG
2
TABLET SL
trezix
1
PA, QLL (186/31)
PA, QLL (124/31)
PA, QLL (186/31)
PA, QLL (124/31)
CLASS IV NARCOTICS
buprenorphine 0.3 mg/ml vial
pentazocine-acetaminophen
1
1
Page 22 of 117
Drug
pentazocine-naloxone hcl
Tier
Restrictions
1
CNS STIMULANT DRUGS
amphetamine
amphetamine
amphetamine
amphetamine
amphetamine
amphetamine
amphetamine
salts 10 mg tab
salts 12.5 mg tb
salts 15 mg tab
salts 20 mg tab
salts 30 mg tab
salts 5 mg tab
salts 7.5 mg tab
CONCERTA ER 18 MG TABLET, -ER 27 MG
TABLET, -ER 54 MG TABLET
CONCERTA ER 36 MG TABLET
d-amphetamine er 10 mg capsule, -10 mg tab
d-amphetamine er 15 mg capsule
d-amphetamine er 5 mg capsule
dexmethylphenidate 10 mg tab
dexmethylphenidate 2.5 mg tab
dexmethylphenidate 5 mg tab
dextroamphetamine 5 mg tab
dextroamphetamine-amphetamine
metadate er
methamphetamine hcl
methylin 10 mg tablet
methylin 20 mg tablet
methylin 5 mg tablet
methylin er 10 mg tablet
methylin er 20 mg tablet
methylphenidate 10 mg tablet
methylphenidate 20 mg tablet
methylphenidate 5 mg tablet
methylphenidate er
methylphenidate hcl solution
METHYLPHENIDATE HCL UNKNOWN
methylphenidate sr
NUVIGIL
PROVIGIL
1
1
1
1
1
1
1
3
QLL
QLL
QLL
QLL
QLL
QLL
QLL
QLL
(186/31)
(155/31)
(124/31)
(93/31)
(62/31)
(372/31)
(248/31)
(31/31)
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
1
3
2
QLL
QLL
QLL
QLL
QLL
QLL
QLL
QLL
(62/31)
(186/31)
(124/31)
(279/31)
(62/31)
(248/31)
(124/31)
(372/31)
QLL (93/31)
QLL
QLL
QLL
QLL
QLL
QLL
QLL
QLL
(310/31)
(155/31)
(620/31)
(310/31)
(155/31)
(310/31)
(155/31)
(620/31)
QLL (155/31)
PA
PA, QLL (62/31)
Page 23 of 117
Drug
Tier
DRUGS TO PREVENT AND TREAT HEADACHES
ascomp with codeine
butalb-caff-acetaminoph-codein
butalbital compound-codeine
butorphanol tartrate aerosol spray
dihydroergotamine mesylate injection
ergotamine-caffeine
MAXALT
MAXALT
MAXALT
MAXALT
10 MG TABLET
5 MG TABLET
MLT 10 MG TABLET
MLT 5 MG TABLET
migergot
MIGRANAL
naratriptan hcl
SUMATRIPTAN
sumatriptan 4 mg/0.5 ml kit, -4 mg/0.5 ml refill,
-4 mg/0.5 ml syrng, -6 mg/0.5 ml inject, -6
mg/0.5 ml refill, -6 mg/0.5 ml syrng
sumatriptan 4 mg/0.5 ml vial
sumatriptan 6 mg/0.5 ml vial
sumatriptan succinate tablet
1
1
1
1
1
1
2
2
2
2
1
3
1
1
1
1
1
1
Restrictions
QLL
QLL
QLL
QLL
(12/30)
(24/30)
(12/30)
(24/30)
QLL (9/28)
QLL (4 ml/28)
QLL (8 ml/28)
QLL (9/31)
HYDANTOINS
CEREBYX
DILANTIN 30 MG CAPSULE, -TABLET CHEWABLE
fosphenytoin sodium
PEGANONE
PHENYTEK
phenytoin sodium extended
phenytoin sodium injection
phenytoin suspension oral
3
2
1
3
2
1
1
1
MAO INHIBITORS
EMSAM
MARPLAN
phenelzine sulfate tablet
tranylcypromine sulfate
3
3
1
1
Page 24 of 117
Drug
Tier
Restrictions
OTHER ANTICONVULSANTS
BANZEL
felbamate
FELBATOL
gabapentin capsule, -solution, -tablet
GABITRIL
GRALISE
HORIZANT
KEPPRA SOLUTION
KEPPRA XR
LAMICTAL ODT
LAMICTAL ODT (BLUE)
LAMICTAL ODT (GREEN)
LAMICTAL ODT (ORANGE)
lamotrigine
levetiracetam
LYRICA 225 MG CAPSULE, -300 MG CAPSULE
LYRICA 25 MG CAPSULE, -50 MG CAPSULE, -75
MG CAPSULE, -100 MG CAPSULE, -150 MG
CAPSULE, -200 MG CAPSULE
primidone tablet
SABRIL
topiragen
topiramate capsule sprinkle, -tablet
VIMPAT
zonisamide
3
1
3
1
2
3
3
2
3
3
3
3
3
1
1
3
3
1
4
1
1
3
1
PA
PA
PA, QLL (31/31)
PA, QLL (62/31)
PA, QLL (93/31)
PA, QLL (186/31), LTD
PA
OTHER ANTIDEPRESSANTS
budeprion sr
budeprion xl 150 mg tablet
budeprion xl 300 mg tablet
bupropion hcl sr
bupropion hcl tablet
bupropion xl
chlordiazepoxide-amitriptyline
CYMBALTA 20 MG CAPSULE
CYMBALTA 30 MG CAPSULE, -60 MG CAPSULE
1
1
1
1
1
1
1
2
2
QLL (93/31)
QLL (31/31)
QLL (62/31), ST
QLL (31/31), ST
Page 25 of 117
Drug
maprotiline hcl
mirtazapine
nefazodone hcl
perphenazine-amitriptyline
PRISTIQ
SAVELLA TABLET
SAVELLA TABLET DOSE PACK
trazodone hcl tablet
venlafaxine hcl
venlafaxine hcl er 150 mg cap
venlafaxine hcl er 37.5 mg cap
venlafaxine hcl er 75 mg cap
Tier
1
1
1
1
3
3
3
1
1
1
1
1
Restrictions
QLL (31/31), ST
PA, QLL (62/31)
PA, QLL (55/365)
QLL (62/31), ST
QLL (31/31), ST
QLL (93/31), ST
OTHER ANTIPARKINSON DRUGS
APOKYN
atamet
AZILECT
bromocriptine mesylate capsule, -tablet
carbidopa-levodopa
COMTAN
LODOSYN
pramipexole dihydrochloride
ropinirole hcl
selegiline hcl capsule, -tablet
STALEVO
STALEVO
STALEVO
STALEVO
STALEVO
STALEVO
ZELAPAR
100
125
150
200
50
75
4
1
3
1
1
2
2
1
1
1
2
2
2
2
2
2
3
QLL (93/31), LTD
OTHER CNS/AUTONOMIC DRUGS
ANTABUSE
atropine sulfate injection
CAMPRAL
depade
disulfiram tablet
3
1
2
1
1
Page 26 of 117
guanidine hcl
Drug
MESTINON SYRUP
MYTELASE
naloxone hcl injection
naltrexone hcl tablet
neostigmine methylsulfate
NUEDEXTA
physostigmine salicylate injection
PROSTIGMIN
pyridostigmine bromide tablet
REGONOL
STRATTERA 10 MG CAPSULE, -40 MG CAPSULE,
-60 MG CAPSULE, -80 MG CAPSULE, -100 MG
CAPSULE
STRATTERA 18 MG CAPSULE
STRATTERA 25 MG CAPSULE
XENAZINE 12.5 MG TABLET
XENAZINE 25 MG TABLET
XYREM
Tier
1
3
2
1
1
1
3
1
2
1
3
3
3
3
4
4
4
Restrictions
PA, QLL (62/31)
QLL (31/31)
QLL (62/31)
QLL (93/31)
PA, QLL (93/31), LTD
PA, QLL (124/31), LTD
PA, QLL (558/31), LTD
SECONDARY AMINES
amoxapine
desipramine hcl tablet
nortriptyline hcl capsule, -solution
protriptyline hcl
1
1
1
1
SEDATIVE/HYPNOTIC DRUGS
chloral hydrate syrup
LUNESTA
zaleplon
zolpidem tartrate tablet
1
3
1
1
QLL (31/31), ST
SELECTIVE SEROTONIN REUPTAKE INHIBITORS
citalopram
citalopram hbr
fluoxetine hcl capsule, -solution, -tablet
fluvoxamine maleate
1
1
1
1
Page 27 of 117
Drug
LEXAPRO 10 MG TABLET
LEXAPRO 5 MG TABLET, -20 MG TABLET
LEXAPRO SOLUTION
paroxetine hcl
selfemra
sertraline hcl solution, -tablet
VIIBRYD 10 MG TABLET
VIIBRYD 20 MG TABLET
VIIBRYD 40 MG TABLET
Tier
3
3
3
1
1
1
3
3
3
Restrictions
PA, QLL (47/31)
PA, QLL (31/31)
PA, QLL (620/31)
PA, QLL (124/31)
PA, QLL (62/31)
PA, QLL (31/31)
SMOKING CESSATION PRODUCTS
buproban
CHANTIX TABLET
CHANTIX TABLET DOSE PACK
NICOTROL
NICOTROL NS
1
3
3
2
2
QLL (336/365)
QLL (106/365)
SUCCINIMIDES
CELONTIN
ethosuximide capsule, -syrup
3
1
TERTIARY AMINES
amitriptyline hcl tablet
clomipramine hcl capsule
doxepin hcl capsule, -solution
imipramine hcl tablet
imipramine pamoate
SURMONTIL
1
1
1
1
1
2
VALPROIC ACID AND DERIVATIVES
DEPACON
divalproex sodium
divalproex sodium er
STAVZOR
valproate sodium injection
valproic acid capsule, -syrup
3
1
1
3
1
1
Page 28 of 117
Drug
Tier
Restrictions
CARDIOVASCULAR MEDICATIONS
AMIODARONES
amiodarone hcl injection, -tablet
pacerone
1
1
ANGIOTENSIN CONVERTING ENZYME INHIBITORS
benazepril hcl
captopril tablet
enalapril maleate tablet
fosinopril sodium
lisinopril tablet
moexipril hcl
perindopril erbumine
quinapril hcl
ramipril
trandolapril
1
1
1
1
1
1
1
1
1
1
ANGIOTENSIN II RECEPTOR ANTAGONISTS
AVAPRO
BENICAR
DIOVAN
losartan potassium
MICARDIS
3
3
2
1
2
ST
ST
ANTIDYSRHYTHMIC DRUGS
disopyramide phosphate
flecainide acetate
mexiletine hcl capsule
NORPACE CR 100 MG CAPSULE
procainamide hcl injection
propafenone hcl
quinidine gluconate
quinidine sulfate tablet, -tablet sustained action
1
1
1
2
1
1
1
1
Page 29 of 117
Drug
Tier
BETA-ADRENERGIC ANTAGONIST DRUGS
acebutolol hcl capsule
atenolol tablet
betaxolol hcl tablet
bisoprolol fumarate
BYSTOLIC
carvedilol
COREG CR
labetalol hcl injection, -tablet
LEVATOL
metoprolol succinate
metoprolol tartrate injection, -tablet
nadolol tablet
pindolol
propranolol hcl capsule sustained action, injection, -solution, -tablet
timolol maleate tablet
1
1
1
1
3
1
3
1
3
1
1
1
1
1
Restrictions
PA
QLL (31/31)
1
CALCIUM ANTAGONISTS
afeditab cr
amlodipine besylate tablet
cartia xt
dilt-cd
diltiazem 24hr er
diltiazem er
diltiazem hcl injection, -tablet
dilt-xr
diltzac er
felodipine er
isradipine
matzim la
nicardipine hcl
nifediac cc
nifedical xl
nifedipine capsule
nifedipine er tablet sustained action
nimodipine
nisoldipine
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
4
1
Page 30 of 117
Drug
taztia xt
verapamil er
verapamil er pm
verapamil hcl capsule 24hr sustained release
pellets, -injection, -tablet, -tablet sustained
action
Tier
Restrictions
1
1
1
1
CARDIAC GLYCOSIDES
digoxin injection, -solution, -tablet
1
CENTRALLY ACTING ANTIHYPERTENSIVES
CATAPRES-TTS 1
CATAPRES-TTS 2
CATAPRES-TTS 3
clonidine
clonidine hcl injection, -tablet
DURACLON
guanabenz acetate tablet
guanfacine hcl
methyldopa
methyldopate hcl
1
1
1
1
1
3
1
1
1
1
DRUGS FOR PHEOCHROMOCYTOMA
DEMSER
DIBENZYLINE
2
2
ENDOTHELIN RECPTR ANTAGONIST
LETAIRIS
TRACLEER
4
4
PA, QLL (31/31), LTD
PA, QLL (62/31), LTD
HMG-COA REDUCTASE INHIBITORS
CADUET
LIPITOR
lovastatin
pravastatin sodium
2
2
1
1
Page 31 of 117
Drug
SIMCOR
simvastatin
VYTORIN
Tier
2
1
3
Restrictions
ST
ST
HYPOLIPOPROTEINEMICS
cholestyramine
cholestyramine light
colestipol hcl
fenofibrate
gemfibrozil tablet
LOFIBRA 160 MG TABLET
LOVAZA
NIASPAN
TRICOR
TRILIPIX
WELCHOL
ZETIA
1
1
1
1
1
2
2
2
2
3
2
2
LOOP DIURETICS
bumetanide
EDECRIN
furosemide injection, -solution, -tablet
SODIUM EDECRIN
torsemide
1
2
1
3
1
NITRATES
DILATRATE-SR
isoditrate
ISORDIL
isosorbide dinitrate
isosorbide mononitrate
nitro-bid
NITRO-DUR 0.3 MG/HR PATCH, -0.8 MG/HR
PATCH
nitroglycerin injection
nitroglycerin patch
NITROLINGUAL
2
1
2
1
1
1
2
1
1
2
Page 32 of 117
Drug
NITROSTAT
Tier
Restrictions
2
OTHER ANTIARRHYTHMICS
ibutilide fumarate
MULTAQ
sorine
sotalol
sotalol af
TIKOSYN
1
2
1
1
1
2
OTHER ANTIHYPERTENSIVES
amlodipine besylate-benazepril
AMTURNIDE
atenolol-chlorthalidone
AVALIDE
benazepril-hydrochlorothiazide
BENICAR HCT
bisoprolol-hydrochlorothiazide
captopril-hydrochlorothiazide
CLORPRES
DIOVAN HCT
enalapril-hydrochlorothiazide
EXFORGE
EXFORGE HCT
fosinopril-hydrochlorothiazide
lisinopril-hydrochlorothiazide
losartan-hydrochlorothiazide
methyldopa-hydrochlorothiazide
metoprolol-hydrochlorothiazide
MICARDIS HCT
moexipril-hydrochlorothiazide
nadolol-bendroflumethiazide
propranolol-hydrochlorothiazid
quinapril-hydrochlorothiazide
reserpine tablet
TEKAMLO
TEKTURNA
TEKTURNA HCT
1
2
1
3
1
3
1
1
2
2
1
2
2
1
1
1
1
1
2
1
1
1
1
1
2
2
2
ST
ST
ST
ST
ST
ST
Page 33 of 117
trandolapril-verapamil
Drug
TRIBENZOR
TWYNSTA
VALTURNA
Tier
1
3
2
2
Restrictions
ST
ST
OTHER CARDIOVASCULAR DRUGS
ISUPREL
midodrine hcl
pentopak
pentoxifylline tablet sustained action
phenylephrine hcl injection
RANEXA ER 1,000 MG TABLET
RANEXA ER 500 MG TABLET
3
1
1
1
1
2
2
QLL (62/31)
QLL (124/31)
OTHER VASODILATING DRUGS
ADCIRCA
BIDIL
diluent for epoprostenol vial
epoprostenol sodium
papaverine hcl injection
REMODULIN
REVATIO TABLET
veletri
VENTAVIS 10 MCG/1 ML SOLUTION
VENTAVIS 20 MCG/1 ML SOLUTION
4
2
1
4
1
4
4
4
4
4
PA, QLL (62/31)
PA, LTD
PA, QLL (93/31)
PA
POTASSIUM SPARING DIURETICS
amiloride hcl tablet
amiloride-hydrochlorothiazide
DYRENIUM
eplerenone
spironolactone tablet
spironolactone-hctz
triamterene-hctz
triamterene-hydrochlorothiazid
1
1
2
1
1
1
1
1
Page 34 of 117
Drug
Tier
THIAZIDE AND RELATED DRUGS
chlorothiazide
chlorothiazide sodium
chlorthalidone
DIURIL
DIURIL SODIUM
hydrochlorothiazide capsule, -tablet
indapamide
methyclothiazide
metolazone
Restrictions
1
1
1
2
3
1
1
1
1
VASODILATOR ANTIHYPERTENSIVES
CARDURA XL
doxazosin mesylate
hydralazine hcl
minoxidil tablet
prazosin hcl
terazosin hcl
3
1
1
1
1
1
QLL (31/31)
1
1
PA
DERMATOLOGICAL MEDICATIONS
ANTIACNE DRUGS
adapalene
benzoyl peroxide 2.5% wash, -4.5% cleanser, 5% wash, -5.75 % wash, -6.5% cleanser, -8.5%
cleanser, -10% wash, -gel, -4% lotion, -8%
lotion
bp 10-1
clindacin p
clindamycin phosphate gel, -lotion, -solution nonoral, -swab medicated
clindamycin-benzoyl peroxide
ery
erythromycin gel, -solution non-oral, -swab
medicated
erythromycin-benzoyl peroxide
metronidazole cream, -gel, -lotion
prascion
1
1
1
1
1
1
1
1
1
Page 35 of 117
Drug
rosaderm cleanser
sodium sulf-sulfur cleanser, -sulf-sulfur wash, lotion, -suspensions, (not oral)
topisulf
tretinoin 0.025% cream, -0.05% cream, -0.1%
cream, -gel
vitazol
zaclir
Tier
Restrictions
1
1
1
1
PA
1
1
ANTIPRURITIC DRUGS
hydroxyzine hcl injection, -syrup, -tablet
hydroxyzine pamoate capsule
1
1
ANTIPSORIASIS AND ANTIECZEMA DRUGS
10 wash
calcipotriene
DOVONEX CREAM
salicylic acid shampoo
seb-prev
selenium sulfide shampoo, -suspension topical
sodium sulfacetamide solution
SORIATANE 17.5 MG CAPSULE, -22.5 MG
CAPSULE
sulfacetamide sodium lotion, -suspension topical
VECTICAL
ZITHRANOL-RR
1
1
3
1
1
1
1
4
1
4
3
KERATOLYTIC DRUGS
CONDYLOX GEL
DURASAL
PODOCON-25
podofilox
salicylic acid gel
salicylic acid liquid
3
3
2
1
1
3
Page 36 of 117
Drug
Tier
ORAL DERMATOLOGICAL DRUGS
8-MOP
amnesteem
claravis
OXSORALEN-ULTRA
sotret
Restrictions
4
1
1
4
1
SCABICIDES
acticin
LINDANE
malathion
permethrin cream
ULESFIA
1
2
1
1
2
TOPICAL ANTI-INFLAMMATORY DRUGS
VOLTAREN GEL
3
QLL (1000/31)
TOPICAL CORTICOSTEROID DRUGS
alclometasone dipropionate
amcinonide
betamethasone dipropionate cream, -gel, -lotion,
-ointment
betamethasone valerate cream, -lotion, ointment
beta-val
clobetasol emollient
clobetasol propionate cream, -gel, -ointment, solution non-oral
desonide cream, -lotion, -ointment
desoximetasone cream, -gel, -ointment
diflorasone diacetate
fluocinolone acetonide cream, -ointment, solution non-oral
fluocinonide cream, -gel, -ointment, -solution
non-oral
fluocinonide emollient
1
1
1
1
1
1
1
1
1
1
1
1
1
Page 37 of 117
Drug
fluocinonide-e
fluticasone propionate cream, -ointment
halobetasol propionate
hydrocortisone 1% cream, -plus 1% cream, -aloe 1% cream, -2.5% cream, -lotion, -1%
absorbase, -1% oint, -1% ointment, -2.5%
ointment
hydrocortisone acetate
hydrocortisone butyrate
hydrocortisone valerate
lidocaine-hydrocortisone cream, -lidocaine 3%-hc
0.5% cream, -lotion
mometasone furoate cream, -ointment, -solution
non-oral
prednicarbate
triamcinolone acetonide cream, -lotion, ointment
triderm
U-CORT
Tier
Restrictions
1
1
1
1
1
1
1
1
1
1
1
1
3
TOPICAL DERMATOLOGICAL DRUGS
ALDARA
aluvea 40% cream
ammonium lactate cream, -lotion
CARAC
ELIDEL
FLUOROPLEX
fluorouracil cream, -solution non-oral
hypercare
imiquimod cream
lactic acid cream, -lotion
PANRETIN
PROTOPIC
PRUDOXIN
REGRANEX
remeven
SANTYL
silver nitrate ointment, -solution
SOLARAZE
2
1
1
3
3
3
1
1
1
1
4
3
2
4
1
2
1
3
PA
PA
Page 38 of 117
Drug
u40
u-kera e urea emollient
urea 40
urea 40% cream, -50% cream, -40% gel, -50%
nail gel, -35% lotion, -40% lotion, -50% nail
stick
urea 40% nail film susp
VEREGEN
x-viate cream, -gel
ZONALON
Tier
Restrictions
1
1
1
1
1
3
1
2
DIAGNOSTIC AND MISCELLANEOUS MEDICATIONS
DIAGNOSTIC PRODUCTS
CHEMET
EXJADE
THYROGEN
2
4
2
LTD
MISCELLANEOUS DRUGS
ADAGEN
4
aminocaproic acid injection, -solution oral, -tablet 1
AMPYRA
4
BUPHENYL
4
COPAXONE
4
CYKLOKAPRON
2
ergoloid mesylates tablet
1
fomepizole
1
GILENYA
4
LYSTEDA
3
ORFADIN
4
THALOMID 150 MG CAPSULE, -200 MG CAPSULE 4
THALOMID 50 MG CAPSULE, -100 MG CAPSULE
4
PA, LTD
PA, QLL (62/31), LTD
PA
QLL (30 ml/30)
PA,
PA,
PA,
PA,
PA
QLL (62/31)
QLL (30/28)
LTD
QLL (62/31)
EAR-NOSE-THROAT MEDICATIONS
DRUGS AFFECTING THE EAR
acetasol hc
acetic acid solution non-oral
acetic acid-aluminum
aero otic hc
antipyrine-benzocaine
1
1
1
1
1
Page 39 of 117
Drug
aurodex
auroguard
borofair
chloroxylenol-pramoxine hcl
chlorphenylcaine
CIPRO HC
CIPRODEX
COLY-MYCIN S
CORTISPORIN-TC
cortomycin
CRESYLATE
DERMOTIC
hydrocortisone-acetic acid
neomycin-polymixin-hc ear susp, -ear susp
neomycin-polymyxin-hydrocort
ofloxacin 0.3% ear drops
ZINOTIC
ZINOTIC ES
Tier
Restrictions
1
1
1
1
1
3
3
3
3
1
2
2
1
1
1
1
2
2
DRUGS AFFECTING THE NOSE
ASTEPRO
azelastine hcl aerosol spray w/pump
flunisolide aerosol spray
fluticasone propionate nasal inhaled steroids
ipratropium bromide aerosol spray
NASONEX
PATANASE
TYZINE
VERAMYST
3
1
1
1
1
3
3
2
2
ST
DRUGS AFFECTING THE THROAT AND MOUTH
chlorhexidine gluconate mouthwash
doxycycline hyclate 20 mg tab
EVOXAC
pilocarpine hcl tablet
triamcinolone acetonide paste
1
1
2
1
1
QLL (93/31)
Page 40 of 117
Drug
Tier
Restrictions
ENDOCRINE MEDICATIONS
ANTITHYROID DRUGS
methimazole tablet
propylthiouracil
1
1
DIPEPTIDYL PEPTIDASE-IV INHIB AND COMBOS
TRADJENTA
3
GLUCOCORTICOID DRUGS
A-HYDROCORT
a-methapred 40 mg vial
ARISTOSPAN
baycadron
betamethasone acetate-sod phos
CELESTONE
cortisone acetate tablet
DEPO-MEDROL 20 MG/ML VIAL
dexamethasone elixir, -solution oral, -tablet
dexamethasone intensol
dexamethasone sodium phosphate injection
hydrocortisone tablet
KENALOG-10
KENALOG-40
methylprednisolone acetate injection
methylprednisolone sod succ
methylprednisolone tablet, -tablet dose pack
prednisolone sodium phosphate solution
prednisolone solution oral
prednisone intensol
prednisone solution, -tablet
SOLU-CORTEF
SOLU-CORTEF (PF)
SOLU-MEDROL
SOLU-MEDROL (PF)
triamcinolone acetonide injection
zema-pak 10 day 1.5 mg tablet, -13 day 1.5 mg
tablet
3
1
3
1
1
2
1
3
1
1
1
1
2
2
1
1
1
1
1
1
1
3
3
3
3
1
1
Page 41 of 117
Drug
Tier
Restrictions
GLUCOSE ELEVATING DRUGS
GLUCAGEN
GLUCAGON EMERGENCY KIT
PROGLYCEM
3
3
2
HYPOGLYCEMIC DRUGS
BYETTA
SYMLIN
SYMLINPEN 120
SYMLINPEN 60
VICTOZA 2-PAK
VICTOZA 3-PAK
2
2
2
2
2
2
QLL
QLL
QLL
QLL
(2.40 ml/28)
(20 ml/28), ST
(10.80 ml/28), ST
(12 pens/28), ST
INSULIN
APIDRA
APIDRA SOLOSTAR
HUMALOG
HUMALOG MIX 50-50
HUMALOG MIX 75-25
HUMULIN 70-30
HUMULIN N
HUMULIN R
LANTUS
LANTUS SOLOSTAR
LEVEMIR
NOVOLIN 70-30 100 UNIT/ML VIAL
NOVOLIN N 100 UNITS/ML VIAL
NOVOLIN R
NOVOLOG
NOVOLOG MIX 70-30
RELION NOVOLIN 70-30 VIAL
RELION NOVOLIN N 100 UNITS/ML
3
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
MINERALOCORTICOID DRUGS
fludrocortisone acetate tablet
1
Page 42 of 117
Drug
Tier
ORAL HYPOGLYCEMICS AND COMBOS
acarbose
ACTOPLUS MET
ACTOPLUS MET XR
ACTOS
AVANDAMET
AVANDARYL
AVANDIA
chlorpropamide
DUETACT
FORTAMET
glimepiride
glipizide er
glipizide tablet
glipizide xl
glipizide-metformin
glyburide micronized
glyburide tablet
glyburide-metformin hcl
glycron
GLYSET
JANUMET
JANUVIA
KOMBIGLYZE XR
metformin hcl
metformin hcl er tablet sustained release 24hr
metformin hcl er unknown
nateglinide
ONGLYZA
PRANDIN
RIOMET
tolazamide
tolbutamide
Restrictions
1
2
2
2
2
2
2
1
2
3
1
1
1
1
1
1
1
1
1
3
2
2
2
1
1
1
1
2
2
3
1
1
OTHER ENDOCRINE DRUGS
ACTONEL 150 MG TABLET
ACTONEL 35 MG TABLET
ACTONEL 5 MG TABLET, -30 MG TABLET
2
2
2
QLL (1/28), ST
QLL (4/28), ST
QLL (31/31), ST
Page 43 of 117
Drug
ALDURAZYME
alendronate sodium
ATELVIA
BONIVA INJECTION
BONIVA TABLET
cabergoline
calcitonin-salmon
CEREDASE
CEREZYME 200 UNITS VIAL
CEREZYME 400 UNITS VIAL
desmopressin acetate aerosol spray w/pump, injection, -solution, -tablet
ELAPRASE
etidronate disodium
EVISTA
FABRAZYME 35 MG VIAL
FABRAZYME 5 MG VIAL
FORTEO
fortical
KUVAN
LUMIZYME
MIACALCIN INJECTION
MYOZYME
NAGLAZYME
pamidronate 30 mg/10 ml vial, -90 mg/10 ml vial
PAMIDRONATE 60 MG/10 ML VIAL
pamidronate disod 30 mg vial, -disod 90 mg vial
PROLIA
RECLAST
SAMSCA 15 MG TABLET
SAMSCA 30 MG TABLET
SENSIPAR 30 MG TABLET
SENSIPAR 60 MG TABLET, -90 MG TABLET
SOMAVERT 10 MG VIAL, -20 MG VIAL
SOMAVERT 15 MG VIAL
STIMATE
VPRIV
XGEVA
ZAVESCA
ZOMETA
Tier
4
1
2
3
3
1
1
4
4
4
1
4
1
2
4
4
4
1
4
4
3
4
4
1
1
1
3
3
4
4
2
4
4
4
3
4
4
4
4
Restrictions
PA, LTD
ST
PA, QLL (3/90), ST
QLL (1/28), ST
LTD
PA, LTD
PA, LTD
PA, LTD
QLL (2.40 pens/28), ST
PA,
PA,
PA
PA,
PA,
PA
PA
LTD
LTD
LTD
LTD
PA, QLL (1/168)
QLL (1/365), ST
PA, QLL (31/31)
PA, QLL (62/31)
PA, LTD
PA, QLL (62/31), LTD
PA
PA, QLL (1/28)
PA, LTD
Page 44 of 117
Drug
Tier
Restrictions
THYROID SUPPLEMENTS
ARMOUR THYROID
levothroid
levothyroxine sodium injection, -tablet
levoxyl
liothyronine sodium injection, -tablet
nature-throid
np thyroid
THYROLAR-1
THYROLAR-1/2
THYROLAR-1/4
THYROLAR-2
THYROLAR-3
TRIOSTAT
unithroid
westhroid
2
1
1
1
1
1
1
2
2
2
2
2
2
1
1
GASTROINTESTINAL MEDICATIONS
ANTIDIARRHEAL DRUGS
diphenoxylate-atropine
loperamide capsule
MOTOFEN
paregoric
1
1
3
1
ANTISPASMODICS/DRUGS AFFECT GI MOTILITY
BENTYL INJECTION
CANTIL
dicyclomine hcl capsule, -injection, -syrup, tablet
ed-spaz
glycopyrrolate injection, -tablet
hyomax
hyoscyamine sulfate drops, -elixir, -tablet, -tablet
dispersible lingual, -tablet sublingual, -tablet
sustained release 12hr
LEVSIN INJECTION
methscopolamine bromide tablet
3
2
1
1
1
1
1
2
1
Page 45 of 117
Drug
metoclopramide hcl injection, -solution oral, tablet
propantheline bromide tablet
SAL-TROPINE
SCOPACE
SCOPOLAMINE HYDROBROMIDE INJECTION
Tier
Restrictions
1
1
2
2
2
ANTIULCER DRUGS
cimetidine injection, -solution, -tablet
famotidine injection, -suspension oral, -20 mg
tablet, -40 mg tablet
nizatidine
pepcid injection
ranitidine hcl capsule, -injection, -syrup, -150 mg
tablet, -300 mg tablet
1
1
1
1
1
IRRITABLE BOWEL DRUGS
AMITIZA
LOTRONEX
2
4
QLL (62/31)
LAXATIVES AND CATHARTICS
OSMOPREP
polyethylene glycol 3350
polyethylene glycol 3350 packet
VISICOL
2
1
1
3
OTHER ANTIULCER DRUGS
CARAFATE SUSPENSION ORAL
misoprostol
sucralfate suspension oral, -tablet
2
1
1
OTHER GI DRUGS
APRISO
ASACOL
ASACOL HD
2
2
2
Page 46 of 117
balsalazide disodium
budesonide ec
Drug
CANASA
COLOCORT
COLYTE WITH FLAVOR PACKETS
COLYTE WITH FLAVOR PACKS
CORTIFOAM
CREON
DIPENTUM
ENTOCORT EC
gavilyte-c
gavilyte-g
gavilyte-n
HALFLYTELY-BISACODYL
HELIDAC
hydrocortisone enema
LIALDA
mesalamine enema
PANCREAZE
PANCRELIPASE 5,000
peg 3350-electrolyte
peg-3350 and electrolytes
peg-3350 with flavor packs
PENTASA
PREVPAC
PROCTOFOAM-HC
procto-pak
proctozone-hc
RELISTOR 12 MG/0.6 ML KIT
RELISTOR 12 MG/0.6 ML VIAL
sulfasalazine dr
sulfasalazine tablet
sulfazine
sulfazine ec
trilyte with flavor packets
ursodiol capsule, -tablet
ZENPEP
Tier
1
1
3
2
3
3
3
2
3
2
1
1
1
3
3
1
3
1
3
3
1
1
1
3
3
2
1
1
3
3
1
1
1
1
1
1
2
Restrictions
PA
Page 47 of 117
Drug
Tier
PROTON PUMP INHIBITORS
DEXILANT
lansoprazole capsule enteric coated, -tablet
omeprazole dr 10 mg capsule, -dr 20 mg capsule
pantoprazole sodium
PROTONIX IV
Restrictions
3
1
1
1
3
QLL
QLL
QLL
QLL
(30/30), ST
(31/31)
(62/31)
(62/31)
4
2
4
PA, QLL (62/31)
PA
PA
4
4
4
4
PA
PA
PA
4
4
4
4
PA
PA
PA
4
4
4
4
4
4
4
PA
PA
PA
IMMUNOLOGICALS AND VACCINES
GROWTH HORMONES AND RELATED
DRUGS
EGRIFTA
GENOTROPIN MINIQUICK 0.2 MG
GENOTROPIN MINIQUICK 0.4 MG, -MINIQUICK
0.6 MG, -MINIQUICK 0.8 MG, -MINIQUICK 1 MG,
-MINIQUICK 1.2 MG, -MINIQUICK 1.4 MG, MINIQUICK 1.6 MG, -MINIQUICK 1.8 MG, MINIQUICK 2 MG, -5 MG CARTRIDGE, -12 MG
CARTRIDGE
HUMATROPE
NORDITROPIN
NORDITROPIN FLEXPRO
NORDITROPIN NORDIFLEX 5 MG/1.5, NORDIFLX 15 MG/1.5
NORDITROPIN NORDIFLX 10 MG/1.5, -30 MG/3
NUTROPIN
NUTROPIN AQ
NUTROPIN AQ NUSPIN 10 PEN CART, -20 PEN
CART
NUTROPIN AQ NUSPIN 5 PEN CART
OMNITROPE
SAIZEN 5 MG VIAL, -8.8 MG CLICK.EASY CARTG
SAIZEN 8.8 MG VIAL
SEROSTIM
TEV-TROPIN
ZORBTIVE
PA, LTD
PA
PA, LTD
IMMUNOLOGICALS AND VACCINES
ACTHIB
2
Page 48 of 117
Drug
ADACEL
ARANESP 25 MCG/0.42 ML SYRING, -25 MCG/ML
VIAL, -40 MCG/0.4 ML SYRINGE, -40 MCG/ML
VIAL
ARANESP 60 MCG/0.3 ML SYRINGE, -60 MCG/ML
VIAL, -100 MCG/0.5 ML SYRINGE, -100 MCG/ML
VIAL, -200 MCG/0.4 ML SYRINGE, -150 MCG/0.3
ML SYRINGE, -200 MCG/ML VIAL, -300 MCG/0.6
ML SYRINGE, -300 MCG/ML VIAL, -500 MCG/1
ML SYRINGE, -150 MCG/0.75 ML VIAL
ATGAM
ATTENUVAX VACCINE WITH DILUENT
BCG VACCINE (TICE STRAIN)
BOOSTRIX
CARIMUNE NF NANOFILTERED
CERVARIX
CINRYZE
COMVAX
DAPTACEL
DECAVAC
DIPHTHERIA-TETANUS TOXOID
ENGERIX-B 10 MCG/0.5 ML PED VL, -10 MCG/0.5
ML SYRN, -20 MCG/ML SYRINGE, -20 MCG/ML
VIAL
ENGERIX-B 10 MCG/0.5 ML PEDI
EPOGEN 10,000 UNITS/ML VIAL, -20,000
UNITS/2 ML VIAL, -20,000 UNITS/ML VIAL, 40,000 UNITS/ML VIAL
EPOGEN 2,000 UNITS/ML VIAL, -3,000
UNITS/ML VIAL, -4,000 UNITS/ML VIAL
GAMASTAN S-D
GAMMAGARD LIQUID
GAMMAGARD S-D
GAMMAPLEX
GAMUNEX
GAMUNEX-C
GARDASIL SYRINGE
GARDASIL VIAL
HAVRIX
HIZENTRA 1 GRAM/5 ML VIAL
HIZENTRA 2 GRAM/10 ML VIAL, -4 GRAM/20 ML
Tier
Restrictions
2
3
PA
4
PA
4
2
3
2
4
2
4
2
2
2
2
2
PA
PA
PA
PA, QLL (20/30)
2
4
PA
2
PA
2
4
4
4
4
4
2
2
2
4
4
PA
PA
PA
PA
PA
PA
PA
PA
Page 49 of 117
Drug
VIAL
IMOVAX RABIES VACCINE
INFANRIX
INFANRIX PF
IPOL
IXIARO
JE-VAX
KEPIVANCE
MENACTRA
MENOMUNE-A-C-Y-W-135
MENVEO A-C-Y-W-135-DIP
MERUVAX II VACCINE W-DILUENT
M-M-R II VACCINE
MOZOBIL
PEDIARIX
PEDVAXHIB
PRIVIGEN
PROCRIT 2,000 UNITS/ML VIAL, -3,000
UNITS/ML VIAL, -4,000 UNITS/ML VIAL, -10,000
UNITS/ML VIAL
PROCRIT 20,000 UNITS/ML VIAL, -40,000
UNITS/ML VIAL
PROQUAD
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ
SYNAGIS 100 MG/1 ML VIAL
SYNAGIS 50 MG/0.5 ML VIAL
TETANUS DIPHTHERIA TOXOIDS
tetanus toxoid adsorbed
TETANUS-DIPHTERIA-DECAVAC
THYMOGLOBULIN
TRIHIBIT
TRIPEDIA
TWINRIX
TYPHIM VI
VAQTA
VARIVAX VACCINE
VIVAGLOBIN
Tier
2
2
2
2
3
2
4
2
2
2
2
2
4
2
2
4
2
4
2
2
2
2
2
4
4
2
1
2
4
2
2
2
2
2
2
4
Restrictions
LTD
PA, QLL (9.60/4)
PA
PA
PA
PA
PA, LTD
PA
PA
Page 50 of 117
Drug
YF-VAX
ZOSTAVAX
Tier
Restrictions
2
2
PA, QLL (1/365)
4
PA, LTD
4
4
4
4
4
4
4
PA, LTD
QLL (4 kits/28)
QLL (4 kits/28)
QLL (14/28), ST
QLL (15 trays/30), ST
PA, QLL (12/30)
2
PA
4
PA
4
4
4
4
PA, QLL (4 syringes/28)
PA, QLL (4 vials/28)
PA, QLL (4 kits/28)
4
4
PA, QLL (4 pens/28)
QLL (12 ml/30)
4
4
4
QLL (12 syringes/30)
PA
PA
4
4
PA, QLL (40/28)
4
4
4
PA, QLL (10/28), LTD
PA, QLL (1/56), LTD
PA, QLL (20.10/30)
INSULIN LIKE GROWTH FACTORS-1
INCRELEX
INTERFERONS
ACTIMMUNE
AVONEX
AVONEX ADMINISTRATION PACK
BETASERON
EXTAVIA
INFERGEN
INTRON A 10 MILLION UNIT/ML, -18 MILLION
UNITS VIAL, -50 MILLION UNITS VIAL
INTRON A 3 MILLION UNIT/ML PEN, -10
MILLION UNITS VIAL
INTRON A 5 MILLION UNIT/ML PEN, -6 MILLION
UNIT/ML VL, -10 MILLION UNIT PEN
PEGASYS 180 MCG/0.5 ML CONV.PK
PEGASYS 180 MCG/ML VIAL
PEGINTRON 50 MCG KIT
PEGINTRON 80 MCG KIT, -120 MCG KIT, -150
MCG KIT
PEGINTRON REDIPEN
REBIF 22 MCG/0.5 ML SYRINGE, -44 MCG/0.5
ML SYRINGE
REBIF TITRATION PACK
SYLATRON
SYLATRON 4-PACK
INTERLEUKIN RECPTR ANTAGONIST
ACTEMRA 200 MG/10 ML VIAL
ACTEMRA 80 MG/4 ML VIAL, -400 MG/20 ML
VIAL
ARCALYST
ILARIS
KINERET
Page 51 of 117
Drug
Tier
Restrictions
INTERLEUKINS
NEUMEGA
PROLEUKIN
4
4
MYELOID STIMULANTS
LEUKINE
NEULASTA
NEUPOGEN
4
4
4
PA
PA
4
4
PA, QLL (93/31), LTD
PA, QLL (31/31), LTD
THROMBOPOIETIC AGENTS
PROMACTA 25 MG TABLET
PROMACTA 50 MG TABLET, -75 MG TABLET
MEDICAL (MISCELLANEOUS) SUPPLIES
DIABETIC SUPPLIES
AIMSCO INS SYR 0.3 ML 29GX1/2, -AIMSCO INS
SYR 0.3 ML 30GX5/16, -AIMSCO INS SYR 0.5 ML
28GX1/2, -AIMSCO INS SYR 0.5 ML 29GX1/2, AIMSCO INS SYR 1 ML 28GX1/2, -AIMSCO INS
SYR 1 ML 29GX1/2, -AIMSCO SYRING 0.3 ML
31GX5/16, -AIMSCO SYRING 0.5 ML 30GX5/16, AIMSCO SYRING 0.5 ML 31GX5/16, -BD INSULIN
SYR 0.3 ML 28GX1/2, -BD INSULIN SYR 0.3 ML
29GX1/2, -BD INSULIN SYR 0.3 ML 30GX1/2, BD INSULIN SYR 0.3ML 31GX5/16, -BD INSULIN
SYR 0.5 ML 28GX1/2, -BD INSULIN SYR 0.5 ML
29GX1/2, -BD INSULIN SYR 0.5 ML 30GX1/2, BD INSULIN SYR 0.5ML 31GX5/16, -BD INSULIN
SYR 1 ML 25GX1, -BD INSULIN SYR 1 ML
25GX5/8, -BD INSULIN SYR 1 ML 26GX1/2, -BD
INSULIN SYR 1 ML 27GX5/8, -BD INSULIN SYR 1
ML 28GX1/2, -BD INSULIN SYR 1 ML 29GX1/2, BD INSULIN SYR 1 ML 30GX1/2, -BD INSULIN
SYR 1 ML 31GX5/16, -BD INSULIN SYRINGE 1
ML, -BD INSULIN U100-3/10 ML SYR, -FIFTY50
INSULIN SYRINGE 0.3 ML, -FIFTY50 INSULIN
SYRINGE 0.5 ML, -FIFTY50 INSULIN SYRINGE 1
2
Page 52 of 117
Drug
ML, -INS SYR 0.3 ML 29GX1/2, -INS SYR 0.3 ML
30GX5/16, -INS SYR 0.5 ML 28GX1/2, -INS SYR
0.5 ML 29GX1/2, -INS SYR 0.5 ML 30GX1/2, -INS
SYR 0.5 ML 30GX5/16, -INS SYR 1 ML 28GX1/2,
-INS SYR 1 ML 29GX1/2, -INS SYR 1 ML
31GX5/16, -INS SYR U100 1 ML 28GX1/2, -INS
SYRIN 0.3 ML 30GX1/2, -INS SYRIN 1 ML
29GX1/2, -INS SYRING 0.3 ML 30GX5/16, -INS
SYRINGE 1 ML 28GX1/2, -INS SYRINGE 3/10 ML,
-INSUL SYR 0.3 ML 31GX5/16, -INSUL SYR 0.5
ML 28GX1/2, -INSUL SYR 0.5 ML 30GX1/2, INSUL SYR 0.5 ML 31GX5/16, -0.3 ML SYRINGE,
-0.5 ML SYRINGE, -1 ML SYRINGE, -1/2 ML
SYRINGE, -3/10 ML SYRINGE, -SYR 0.3 ML
29GX1/2, -SYR 0.5 ML 28GX1/2, -SYR 1 ML
29GX1/2, -SYR 1 ML 30GX5/16, -SYR 1 ML
31GX5/16, -SYRIN 0.3 ML 29GX1/2, -SYRIN 0.3
ML 30GX1/2, -SYRIN 0.3 ML 30GX5/16, -SYRIN
0.3 ML 31GX5/16, -SYRIN 0.3 ML 31GX5/16, SYRIN 0.5 ML 28GX1/2, -SYRIN 0.5 ML 29GX1/2,
-SYRIN 0.5 ML 30GX1/2, -SYRIN 0.5 ML
30GX5/16, -SYRIN 0.5 ML 30GX5/16, -SYRIN 0.5
ML 31GX5/16, -SYRIN 1 ML 29GX1/2, -1 ML
28GX1/2, -1 ML 29GX1/2, -1 ML 30GX1/2, -1 ML
31GX5/16, -1 ML-HARD PK, -U100 0.5 ML, -U100
1 ML, -INSULN SYR
1ST TIER UNIFINE PENTIPS PLUS
AIMSCO INS SYR 1 ML 30GX5/16, -CAREONE
INS SYR 1 ML 30GX5/16, -INS SYR 1 ML
30GX5/16, -INS SYRINGE 1 ML 30GX1/2, -INS
SYRINGE 1 ML 30GX5/16, -1 ML 30GX5/16, 30GX1 ML SYR, -PREFPLS INS SYR 1 ML
30GX5/16, -RELION INS SYR 1 ML 30GX5/16, RELION INSULIN SYR 0.3 ML, -RELION INSULIN
SYR 0.5 ML, -RELION INSULIN SYRINGE 1 ML, RELION SYRING 0.5 ML 31GX5/16, -U100 1 ML
30GX5/16, -ULTCARE INS SYR 1 ML 30GX5/16, WDMEDIC INS SYR 1 ML 30GX5/16
AIMSCO MINI ULTRA-THIN II
AIMSCO ULTRA THIN II
ALCOHOL PADS
ALCOHOL PREP PADS
ALCOHOL PREP SWABS
Tier
Restrictions
2
3
2
2
2
2
2
Page 53 of 117
Drug
ALCOHOL SWAB
ALCOHOL SWABS
ALCOHOL WIPES
AURORA PEN NEEDLE 6MM 31G, -AURORA PEN
NEEDLES 12MM 29G, -AURORA PEN NEEDLES
8MM 31G, -BD PEN NEEDLE 29GX1/2, -BD PEN
NEEDLE 29GX3/16, -BD PEN NEEDLE 29GX5/16,
-BD PEN NEEDLE MINI 31GX3/16, -BD PEN
NEEDLE NANO 32GX5/32, -BD PEN NEEDLE
ORIG 29GX1/2, -BD PEN NEEDLE SHORT
31GX5/16, -CLICKFINE PEN NDL 31GX1/4, CLICKFINE PEN NDL 31GX5/16, -LIVE BETTER
PEN NEEDLE 6MM 31G, -LIVE BETTER PEN
NEEDLES 12MM, -LIVE BETTER PEN NEEDLES
8MM, -MS PEN NEEDLE 6MM 31G, -12MM 29G
NEEDLES, -8MM 31G NEEDLES, -31GX3/16, 31GX5/16, -6MM 31G, -S 12MM 29G, -S 29G, -S
31G, -S 31G X 5/16, -S 8MM 31G, -TODAY'S HLT
PN NEEDLE 12MM 29G, -TODAY'S HLTH PN
NEEDLE 6MM 31G, -TODAY'S HLTH PN NEEDLE
8MM 31G, -UNIFINE PENTIP 6MM 31G
AUTO INJECTOR
AUTOJECT 2
AUTOPEN
BD LUER-LOK SYRINGE 1 ML
BD SAFETYGLIDE SYRINGE 27GX5/8
CLICKFINE
CURAD GAUZE PADS
CURITY ALCOHOL PREPS
CURITY SPONGE
DRUG MART ULTRA COMFORT SYR, -1 ML
30GX5/16, -1 ML SYRINGE
EASY COMFORT 0.3 ML SYRINGE, -COMFORT
0.5 ML SYRINGE
EASY COMFORT INSULIN 1 ML SYR
EASY TOUCH INSULIN SYR 1 ML
EASY TOUCH NEEDLE DISPOSABLE, -INSULIN
SYR 0.3 ML, -INSULIN SYR 0.5 ML
EXEL INSULIN SYRINGE
FREESTYLE PREC 0.5 ML 30GX5/16, -PREC 0.5
ML 31GX5/16, -PREC 1 ML 31GX5/16
FREESTYLE PREC 1 ML 30GX5/16
Tier
Restrictions
2
2
2
2
2
2
2
2
2
2
2
2
3
3
2
3
3
2
2
2
3
Page 54 of 117
Drug
GLUCOPRO INSUL SYR U100 0.3 ML, -INSUL SYR
U100 0.5 ML, -INSULIN SYR 0.5 ML, -INSULIN
SYR 1 ML, -U100 INSUL SYR 0.3 ML
GLUCOPRO INSULIN SYR U100 1 ML, -SYRINGE
U100 1 ML
HUMAPEN LUXURA HD
HUMAPEN MEMOIR
IN CONTROL PEN NEEDLE
INJECT-EASE
INSULIN PEN NEEDLE
INSULIN SYR 1/2 ML BULK PACK, -1 ML SYRN
27X1/2, -1 ML SYRN 28GX1/2, -INSUL SYR U100,
-INSUL SYR U100 0.5 ML, -INSUL SYR U100 1
ML, -INSULIN SYR 0.3 ML, -INSULIN SYR 0.5 ML,
-INSULIN SYR U-100, -INSULIN SYRN 3/10 ML, SYRINGE 0.3 ML, -SYRINGE 0.5 ML, -SYRINGE 1
ML
INSULIN SYRINGE 0.3 ML, -INSULIN SYRINGE
0.5 ML, -INSULIN SYRINGE 1 ML, -0.3 ML, -0.5
ML
INSUMED
INSUPEN
INTEGRA SYRINGE DISPOSABLE SYRINGE, -BD
INTEGRA SYR 1 ML 29GX1/2
LISCO
LITE TOUCH INSULIN 0.3 ML SYR, -INSULIN 0.5
ML SYR, -INSULIN SYR 0.3 ML, -INSULIN SYR
0.5 ML, -INSULIN SYR 1 ML
LITE TOUCH INSULIN 1 ML SYR
LITE TOUCH INSULIN PEN NEEDLES
MAGELLAN INSULIN SAFETY SYRNG
MAGELLAN INSULIN SYRINGE
MONOJECT 0.5 ML SYRN 28GX1/2
MONOJECT INSULIN SAFETY SYRNG
MONOJECT INSULIN SYR 1 ML
MONOJECT SAFETY SYRINGE
NORDIPEN 15
NORDIPEN 5
NOVOFINE 32
NOVOFINE AUTOCOVER
NOVOPEN 3
Tier
Restrictions
2
3
2
2
2
2
2
2
2
3
2
2
3
2
3
2
2
2
2
2
3
2
2
2
2
2
2
Page 55 of 117
Drug
NOVOPEN JR
ORSINI INSUL SYR U100 0.5 ML
ORSINI INSUL SYR U100 1 ML
PEN NEEDLES
PRECISION
PRODIGY INSULIN SYRINGE
PRODIGY PEN NEEDLE
RELION PEN 29G NEEDLE, -RELION PEN 31G
NEEDLE
SAFESNAP INSULIN SYRINGE
SAFETY SYRINGE WITH SHIELD
SAFETYGLIDE INSULIN SYRINGE
SINGLE USE SWAB
SURE COMFORT 1 ML SYRINGE
SURE COMFORT ALCOHOL
SURE COMFORT NEEDLE DISPOSABLE, -0.3 ML
SYRINGE, -0.5 ML SYRINGE, -3/10 ML SYRINGE
SURE-FINE PEN NEEDLES
SURE-JECT INSU SYR U100 0.3 ML, -INSU SYR
U100 0.5 ML, -INSU SYR U100 1 ML, -1 ML
SURE-JECT INSUL SYR U100 1 ML
SURE-PREP ALCOHOL PREP PADS
TERUMO INSULIN SYRINGE
TERUMO SURGUARD
THINPRO INSULIN SYRINGE
TOPCARE CLICKFINE
TOPCARE ULTRA COMFORT
ULTICARE NEEDLE DISPOSABLE, -INSUL SYR
U100 0.3 ML, -INSUL SYR U100 0.5 ML, INSULIN SYR U100 1 ML
ULTIGUARD SYRINGE EMPTY DISPOSABLE
ULTILET ALCOHOL SWAB
ULTILET INSULIN SYRINGE 1 ML
ULTRA COMFORT NEEDLE DISPOSABLE, -0.3 ML
29GX1/2, -0.3 ML 30GX5/16, -0.3 ML 31GX5/16,
-0.3 ML SYRINGE, -0.5 ML 28GX1/2, -0.5 ML
29GX1/2, -0.5 ML 30GX5/16, -0.5 ML 31GX5/16,
-0.5 ML SYR, -0.5 ML SYRINGE, -1 ML 28GX1/2,
-1 ML 29GX1/2, -1 ML 31GX5/16, -3/10 ML SYR
ULTRACOMFORT 30GX0.5 ML SYR, -30GX1 ML
SYRINGE, -31GX0.5 ML SYR, -31GX1 ML
Tier
Restrictions
2
2
3
2
2
2
2
3
2
2
2
2
3
2
2
2
2
3
2
2
2
2
2
3
2
2
2
3
2
2
Page 56 of 117
Drug
SYRINGE, -NEEDLE DISPOSABLE, -SYRINGE
EMPTY DISPOSABLE
UNIFINE PENTIPS
VANISHPOINT U-100 29X1/2 SYR
VERSALON SPONGE
WEBCOL
Tier
Restrictions
2
2
3
2
PHARMACEUTICAL NECESSITIES
PEG 3350-GRX
3
MUSCULOSKELETAL MEDICATIONS
CNS MUSCLE RELAXANTS
cafgesic forte
carisoprodol 350 mg tablet
carisoprodol compound
carisoprodol compound-codeine
carisoprodol-aspirin
chlorzoxazone
cyclobenzaprine 5 mg tablet, -10 mg tablet
methocarbamol tablet
orphenadrine citrate injection, -tablet sustained
action
orphenadrine compound
orphenadrine compound forte
RILUTEK
1
1
1
1
1
1
1
1
1
1
1
4
DIRECT MUSCLE RELAXANTS
baclofen tablet
dantrolene sodium capsule
DYSPORT
GABLOFEN
tizanidine hcl tablet
XEOMIN 100 UNITS VIAL
XEOMIN 50 UNITS VIAL
1
1
3
3
1
3
3
PA
PA
PA, QLL (8/84)
DRUGS TO PREVENT AND TREAT GOUT
allopurinol sodium
1
Page 57 of 117
allopurinol tablet
Drug
COLCRYS
KRYSTEXXA
probenecid
probenecid-colchicine
ULORIC 40 MG TABLET
ULORIC 80 MG TABLET
Tier
1
2
4
1
1
2
2
Restrictions
QLL (31/31), ST
ST
NON-STEROIDAL ANTIINFLAMMATORY AGENTS
ARTHROTEC 50
ARTHROTEC 75
CELEBREX
diclofenac potassium
diclofenac sodium tablet enteric coated, -tablet
sustained release 24hr
etodolac
fenoprofen calcium tablet
flurbiprofen tablet
ibuprofen suspension oral, -400 mg tablet, -600
mg tablet, -800 mg tablet
indomethacin capsule, -capsule sustained action,
-injection
ketoprofen capsule, -capsule 24hr sustained
release pellets
ketorolac tromethamine injection
ketorolac tromethamine tablet
meclofenamate sodium capsule
meloxicam suspension oral, -tablet
nabumetone
naproxen sodium 275 mg tab, -550 mg tab
naproxen suspension oral, -tablet, -tablet enteric
coated
oxaprozin
piroxicam capsule
sulindac tablet
tolmetin sodium
3
3
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QLL (20/5)
1
1
1
1
Page 58 of 117
Drug
Tier
OTHER DRUGS FOR ARTHRITIS
CUPRIMINE
DEPEN
myochrysine
RIDAURA
SUPARTZ
SYNVISC
SYNVISC-ONE
SYPRINE
2
2
1
2
4
4
4
2
Restrictions
PA
PA
PA
SALICYLATES AND RELATED DRUGS
choline mag trisalicylate
diflunisal tablet
mst 600
salsalate tablet
1
1
1
1
NUTRITION,BLOOD MODIFIERS,ELECTROLYTES
ANTIPLATELET DRUGS
AGGRENOX
cilostazol
dipyridamole tablet
EFFIENT
PLAVIX
ticlopidine hcl
2
1
1
2
2
1
QLL (31/31)
BLOOD DETOXICANTS
constulose
enulose
FOSRENOL
generlac
lactulose
RENAGEL
RENVELA
1
1
3
1
1
2
2
ELECTROLYTES, IRRIGATING SOLUTIONS, ETC.
alcohol in dextrose
1
Page 59 of 117
Drug
AMINOSYN
AMINOSYN II
AMINOSYN II 3.5% M-DEXTROSE 5%
AMINOSYN II 3.5%-DEXTROSE 25%
AMINOSYN II 3.5%-DEXTROSE 5%
AMINOSYN II 4.25% M-DEXT 10%
AMINOSYN II 4.25%-DEXTROSE 25%
AMINOSYN II 5% IN 25% DEXTROSE
AMINOSYN II IN DEXTROSE
AMINOSYN II WITH LYTES-CA-DW
AMINOSYN M
AMINOSYN WITH ELECTROLYTES
AMINOSYN-HBC
AMINOSYN-HF
AMINOSYN-PF
AMINOSYN-RF
AMMONIUM CHLORIDE INJECTION
calcium gluconate injection
CLINIMIX
CLINIMIX E 2.75%-10% SOLUTION, -2.75%-5%
SOLUTION, -4.25%-25% SOLUTION, -4.25%5% SOLUTION, -5%-15% SOLUTION, -5%-20%
SOLUTION, -5%-25% SOLUTION
CLINISOL
CYSTAGON
d5w/kcl 10 meq/l iv solution, -d5w-kcl 30 meq/l
iv solution
delflex with 1.5% dextrose
delflex with 2.5% dextrose
delflex with 4.25% dextrose
dextrose 10%-1/4ns
dextrose 10%-1/4ns-kcl
dextrose 5%-1/2ns-kcl
dextrose 5%-1/3ns-kcl
dextrose 5%-1/4ns-kcl
dextrose 5%-electrolyte #48
dextrose 5%-ns-kcl
dextrose in ringers injection
dextrose in water
dextrose with sodium chloride
Tier
Restrictions
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
1
3
3
3
2
1
LTD
1
1
1
1
1
1
1
1
1
1
1
1
1
Page 60 of 117
Drug
DIANEAL PD-2 W-1.5% DEXTROSE
DIANEAL PD-2 W-2.5% DEXTROSE
DIANEAL PD-2 W-4.25% DEXTROSE
DIANEAL WITH 1.5% DEXTROSE
DIANEAL WITH 2.5% DEXTROSE
DIANEAL WITH 4.25% DEXTROSE
FREAMINE HBC
FREAMINE III
FREAMINE III WITH ELECTROLYTES
HEPATAMINE
HEPATASOL
INPERSOL WITH 1.5% DEXTROSE
INPERSOL WITH 4.25% DEXTROSE
IONOSOL B WITH DEXTROSE 5%
IONOSOL MB-DEXTROSE 5%
IONOSOL T-DEXTROSE 5%
ISOLYTE H WITH DEXTROSE
ISOLYTE M WITH DEXTROSE
ISOLYTE P WITH DEXTROSE
ISOLYTE S
ISOLYTE S WITH DEXTROSE
lactated ringers
magnesium sulfate injection
MAGNESIUM SULFATE-D5W
NEPHRAMINE
NORMOSOL-M AND DEXTROSE
NORMOSOL-R
NORMOSOL-R AND DEXTROSE
NORMOSOL-R PH 7.4
NOVAMINE
nutrilyte
nutrilyte ii
PHYSIOLYTE
PHYSIOSOL
PLASMA-LYTE
PLASMA-LYTE
PLASMA-LYTE
PLASMA-LYTE
PLASMA-LYTE
PLASMA-LYTE
148
148 IN DEXTROSE
56
56 IN DEXTROSE
A PH 7.4
R
Tier
Restrictions
2
2
2
2
2
2
3
3
3
3
3
2
3
3
3
3
3
3
3
3
3
1
1
2
3
3
3
3
3
3
1
1
3
3
3
3
3
3
3
3
Page 61 of 117
Drug
potassium chl-normal saline
potassium chloride-nacl
potassium ph 3mm/ml vial
Tier
Restrictions
1
1
1
PREMASOL
3
PROCALAMINE
3
PROSOL
3
RENAMIN
3
ringers injection
1
ringers irrigation
1
saline 0.45% soln-excel con, -0.45% soln, -saline 1
0.9% soln-excel cont, -0.9% soln, -0.9% soln., 0.9% solution, -cl 2.5 meq/ml vial, -3% iv soln, 4 meq/ml vl, -5% iv soln
sodium acetate injection
sodium bicarbonate injection
sodium lactate injection
sterile water for irrigation
tis-u-sol
TPN ELECTROLYTES
TPN ELECTROLYTES II
TRAVASOL
TROPHAMINE
1
1
1
1
1
2
2
3
3
FLUORIDE PRODUCTS
epiflur 0.5 mg tablet chewable, -1 mg tablet
chewable
fluor-a-day 0.5 mg tab chew, -1 mg tablet chew
fluoride 0.5 mg chew tablet, -1 mg chew tablet
fluoritab tablet chewable
ludent fluoride 0.5 mg tb chew, -1 mg tab chew
PREVIDENT 5000
PREVIDENT SOLUTION NON-ORAL
renaf fluoride 0.5 mg tab chew, -fluoride 1 mg
tab chew
sf
sf 5000 plus
sodiphluor
sodium fluoride drops, -tablet, -0.5 mg(1.1 mg)
stannous fluoride solution
1
1
1
1
1
2
2
1
1
1
1
1
1
Page 62 of 117
Drug
Tier
Restrictions
INJECTABLE ANTICOAGULANTS
ARIXTRA 2.5 MG SYRINGE
ARIXTRA 5 MG SYRINGE, -7.5 MG SYRINGE, -10
MG SYRINGE
3
4
QLL (60/365)
QLL (60/365)
enoxaparin 30 mg/0.3 ml syr, -40 mg/0.4 ml syr,
-60 mg/0.6 ml syr
1
ENOXAPARIN 80 MG/0.8 ML SYR, -100 MG/ML
SYR, -120 MG/0.8 ML SYR, -150 MG/ML SYR
4
QLL (60/365)
fondaparinux 2.5 mg/0.5 ml syr
fondaparinux 5 mg/0.4 ml syr, -7.5 mg/0.6 ml
syr, -10 mg/0.8 ml syr
1
4
QLL (60/365)
QLL (60/365)
FRAGMIN 2,500 UNITS SYRINGE, -5,000 UNITS
SYRINGE
FRAGMIN 7,500 UNITS SYRINGE, -10,000 UNITS
SYRINGE, -12,500 UNITS SYRINGE, -15,000
UNITS SYRINGE, -18,000 UNITS SYRINGE, 25,000 UNITS/ML VIAL
3
QLL (60/365)
4
QLL (60/365)
1
1
PA
heparin lock flush 100 unit/ml
heparin sod 1,000 unit/ml vial, -sod 2,000
unit/ml vial, -sod 2,500 unit/ml vial, -sod 5,000
unit/ml vial, -sod 10,000 unit/ml vl, -sod 20,000
unit/ml vl
heparin sod 5,000 unit/ml syr, -sod 5,000 unit/
0.5 ml, -sod 5,000 unit/0.5 ml
heparin sodium in 0.45% nacl
heparin-d5w 20,000 unit/500 ml
heparin-d5w 25,000 unit/500 ml, --d5w 10,000
unit/100 ml, --d5w 25,000 unit/250 ml
heparin-ns 1,000 unit/500 ml
heparin-ns 2,000 unit/1,000 ml
LOVENOX 300 MG VIAL, -300 MG/3 ML VIAL
1
1
1
1
1
1
4
PA
PA
PA
QLL (60/365)
ORAL ANTICOAGULANTS, VITAMIN K
jantoven
PRADAXA
warfarin sodium tablet
1
2
1
Page 63 of 117
Drug
Tier
POTASSIUM REMOVING RESINS
kalexate
KAYEXALATE
kionex suspension oral
sodium polystyrene sulfonate powder
sodium polystyrene sulfonate suspension oral
sps
Restrictions
1
2
1
1
1
1
POTASSIUM SUPPLEMENTS
dextrose in lactated ringers
ed k+10
EFFER-K 10 MEQ TABLET EFF, -20 MEQ TABLET
EFF
epiklor
k effervescent
kaon-cl 10
kcl 20 meq in d5w solution, -kcl 40 meq in d5w
solution
klor-con 10
klor-con 20 meq packet
klor-con 8
klor-con m10
klor-con m15
klor-con m20
MICRO-K 8 MEQ EXTENCAPS
potassium acetate injection
potassium bicarbonate tablet effervescent
potassium chloride capsule sustained action, injection, -solution, -tablet effervescent, -tablet
sust.releaseparticles/crystals, -tablet sustained
action
potassium chloride in d5lr
sodium citrate & citric acid
1
1
3
1
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
THERAPEUTIC VITAMINS AND MINERALS
calcitriol 1 mcg/ml vial
calcitriol capsule, -1 mcg/ml ampul, -2 mcg/ml
1
1
PA
Page 64 of 117
Drug
vial, -solution
calcium acetate capsule
CARNITOR INJECTION
eliphos
HECTOROL 2 MCG/ML VIAL, -4 MCG/2 ML VIAL
HECTOROL CAPSULE, -4 MCG/2 ML AMPUL
levocarnitine injection, -solution, -tablet
PHOSLYRA
ZEMPLAR
Tier
1
3
1
2
2
1
3
3
Restrictions
PA
PA
PA
PA
VITAMINS AND MINERALS AND RELATED PRODUCTS
INTRALIPID
LIPOSYN II
2
3
1
1
1
1
liposyn iii
multi-vitamin w-fluoride-iron
multivitamins w-fluoride-iron
multivitamins with fluoride drops, -multivit-fluor
0.25 mg tab chw, -mult-vit-fluor 0.5 mg tab chw,
-multivit-fluor 0.5 mg tab, -multivit-fluor 0.5 mg
tab chew
multivit-fluor 0.25 mg tab chw, -multivit-fluor 0.5 1
mg tab chw
multivit-fluor 0.5 mg tab chew
1
MVC-FLUORIDE 0.5 MG TAB CHEW
phluorivit
phluorivit + fe
polyvitamin with iron-fluoride
polyvitamins-fluoride
triphluorivit
tri-vit with fluoride-iron
tri-vitamin with fluoride
tri-vitamin with iron-fluoride
2
1
1
1
1
1
1
1
1
OBSTETRICAL AND GYNECOLOGICAL MEDICATIONS
ANDROGEN DRUGS
ANADROL-50
ANDRODERM
ANDROGEL 1% GEL PUMP, -1%(2.5G) GEL
PACKET
4
2
3
PA
PA
Page 65 of 117
Drug
ANDROGEL 1.62% GEL PUMP, -1%(5G) GEL
PACKET
danazol capsule
FIRST-TESTOSTERONE
FIRST-TESTOSTERONE MC
oxandrolone tablet
STRIANT
TESTIM
TESTOPEL
testosterone cyp 100 mg/ml
testosterone cyp 200 mg/ml
testosterone enanthate injection
Tier
Restrictions
3
PA
1
3
3
1
3
3
3
1
1
1
PA
PA
PA
PA
CONTRACEPTIVES
altavera
amethia
amethyst
apri
aranelle
aviane
azurette
balziva
briellyn
camrese
caziant
cesia
cryselle
cyclafem
emoquette
enpresse
gianvi
gildess fe
introvale
jolessa
junel
junel fe
kariva
kelnor 1-35
leena
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Page 66 of 117
Drug
lessina
levonorgestrel
levora-28
loryna
low-ogestrel
lutera
microgestin
microgestin fe
mononessa
necon
next choice
norgestimate-ethinyl estradiol
norgestrel-ethiny estra
nortrel
NUVARING
ocella
ogestrel
orsythia
ORTHO EVRA
PLAN B
PLAN B ONE-STEP
portia
previfem
quasense
reclipsen
solia
sprintec
sronyx
syeda
tilia fe
tri-legest fe
trinessa
tri-previfem
tri-sprintec
trivora-28
velivet
zarah
zenchent
zeosa
zovia 1-35e
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1
3
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Restrictions
QLL (3/28)
Page 67 of 117
zovia 1-50e
Drug
Tier
Restrictions
1
ESTROGEN DRUGS
CENESTIN
DELESTROGEN
DEPO-ESTRADIOL
DIVIGEL
ELESTRIN
ENJUVIA
ESTRACE CREAM WITH APPLICATOR
estradiol patch transdermal weekly
estradiol tablet
estradiol valerate injection
ESTRASORB
ESTRING
estropipate
EVAMIST
FEMRING
FEMTRACE 0.45 MG TABLET, -0.9 MG TABLET
GYNODIOL
MENEST
MENOSTAR
PREMARIN CREAM WITH APPLICATOR, -TABLET
PREMARIN INJECTION
VAGIFEM
3
3
3
3
3
3
3
1
1
1
3
3
1
3
3
3
3
3
3
2
3
3
QLL (4/28)
QLL (4/28)
ESTROGEN/PROGESTIN COMBINATIONS
ACTIVELLA 0.5-0.1 MG TABLET
ANGELIQ
CLIMARA PRO
COMBIPATCH
estradiol-norethindrone acetat
FEMHRT 1/5 TABLET
jevantique
jinteli
mimvey
PREFEST
PREMPHASE
2
3
3
3
1
3
1
1
1
3
2
QLL (4/28)
QLL (8/28)
Page 68 of 117
Drug
PREMPRO
Tier
Restrictions
2
OB/GYN TOPICAL ANTIINFECTIVES
ACID JELLY
CLEOCIN SUPPOSITORY VAGINAL
clindamycin phosphate cream with applicator
metronidazole gel with applicator
vandazole
2
2
1
1
1
OXYTOCICS
METHERGINE INJECTION
methylergonovine maleate
oxytocin injection
3
1
1
PRENATAL VITAMINS
cavan one omega
cavan-folate ob
cavan-heme ob
cavan-heme omega
co-natal fa
corenate-dha
dualvit ob
edge ob
elite-ob 400
folcal dha
folcaps omega-3
inatal advance
inatal gt
inatal ultra
multinatal plus tablet
multi-nate dha extra
mynatal
mynatal advance
mynatal plus
mynatal-z
mynate 90 plus
ob + dha
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Page 69 of 117
Drug
ob 90 + dha
ob-natal one
pnv-dha + docusate
pnv-total
pr natal 430 ec
prenacare
prenafirst
prenaplus
prenatabs fa
prenatabs obn
prenatabs rx
prenatal 19
prenatal ad
prenatal low iron
prenatal multivitamin w-iron
prenatal plus
prenatal-u
prenate plus
re-nata 29 ob
se-care conceive
se-care gesture
se-natal 19
se-natal 90
se-natal one
se-plete dha
setonet
setonet-ec
taron ec calcium
taron-bc
taron-duo ec
taron-ec cal
taron-prex prenatal
tri rx
triadvance
triveen-duo dha
triveen-ten
triveen-u
ultimatecare one
vemavite-prx 2
vinacal
Tier
Restrictions
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Page 70 of 117
vinate az
vinate az extra
vinate c
vinate calcium
vinate care
vinate gt
vinate ic
vinate ii
vinate one
vinate pn care
vinate ultra
vinate-m
vitafol-ob
vitafol-pn
vitaphil
vitaphil + dha
vol-plus
zatean-ch
Drug
Tier
Restrictions
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PROGESTIN DRUGS
camila
DEPO-SUBQ PROVERA 104
errin
heather
jolivette
MAKENA
medroxyprogesterone acetate injection, -tablet
MICRONOR
nora-be
norethindrone
norethindrone acetate tablet
PROMETRIUM
1
3
1
1
1
4
1
3
1
1
1
3
SPECIALIZED OB/GYN DRUGS
chorionic gonadotropin injection
leuprolide acetate injection
LUPRON DEPOT 11.25 MG 3MO KIT, -22.5 MG
3MO KIT
1
1
3
PA
PA
PA, QLL (1/84)
Page 71 of 117
LUPRON
LUPRON
LUPRON
LUPRON
LUPRON
Drug
DEPOT 3.75 MG KIT
DEPOT 7.5 MG KIT
DEPOT-4 MONTH KIT
DEPOT-PED 11.25 MG KIT, -15 MG KIT
DEPOT-PED 7.5 MG KIT
novarel
SUPPRELIN LA
SYNAREL
Tier
3
4
3
4
4
1
4
4
PA,
PA,
PA,
PA,
PA
Restrictions
QLL (1/28)
QLL (1/28)
QLL (1/112)
QLL (1/28)
PA
OPHTHALMIC MEDICATIONS
ANTIGLAUCOMA DRUGS
acetazolamide capsule sustained action, -tablet
acetazolamide sodium
apraclonidine hcl
AZOPT
betaxolol hcl drops
BETIMOL
BETOPTIC S
brimonidine tartrate
carteolol hcl
COMBIGAN
dorzolamide hcl
dorzolamide-timolol
IOPIDINE
ISOPTO CARBACHOL
latanoprost
levobunolol hcl
LUMIGAN
methazolamide tablet
metipranolol
PHOSPHOLINE IODIDE
pilocarpine hcl drops
PILOPINE HS
timolol maleate drops, -gel-forming solution
TIMOPTIC 0.5% EYE DROPS
TRAVATAN Z
XALATAN
1
1
1
3
1
3
3
1
1
3
1
1
3
3
1
1
2
1
1
3
1
3
1
2
3
2
Page 72 of 117
Drug
Tier
OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS
BLEPHAMIDE
BLEPHAMIDE S.O.P.
dexasporin
neomycin-bacitracin-poly-hc
neomycin-poly-hc eye drops
neomycin-polymyxin-dexameth
poly-dex
POLY-PRED
PRED-G
sulfacetamide-prednisolone
TOBRADEX OINTMENT
tobramycin-dexamethasone
ZYLET
Restrictions
3
3
1
1
1
1
1
3
3
1
2
1
3
OPHTHALMIC CORTICOSTEROID DRUGS
ALREX
dexamethasone sodium phosphate drops
DUREZOL
fluorometholone suspension drops
FML FORTE
FML S.O.P.
LOTEMAX SUSPENSION DROPS
MAXIDEX
PRED MILD
prednisolone acetate suspension drops
prednisolone sodium phosphate drops
VEXOL
3
1
3
1
3
3
3
3
3
1
1
3
OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS
ak-poly-bac
aktob
AZASITE
bacitracin 500 unit/gm ointmnt
bacitracin-polymyxin
BESIVANCE
CILOXAN OINTMENT
1
1
3
1
1
3
3
Page 73 of 117
Drug
ciprofloxacin hcl drops
erythromycin ointment
garamycin drops
gentak
gentamicin sulfate drops, -3 mg/gm eye oint
gentasol
levofloxacin drops
MOXEZA
neomycin-bacitracin-polymyxin
neomycin-polymyxin-gramicidin
ofloxacin 0.3% eye drops
polycin-b
polymyxin b sul-trimethoprim
POLYTRIM
romycin
sulfacetamide sodium drops
sulfamide
tobramycin sulfate drops
tobrasol
TOBREX OINTMENT
VIGAMOX
ZYMAR
ZYMAXID
Tier
Restrictions
1
1
1
1
1
1
1
3
1
1
1
1
1
3
1
1
1
1
1
2
3
2
2
OPHTHALMIC TOPICAL ANTIVIRAL DRUGS
trifluridine drops
1
OTHER OPHTHALMIC DRUGS
ACUVAIL
ak-con
ak-dilate 10% eye drops
akorn balanced salt
ALAMAST
ALOCRIL
ALOMIDE
altafrin
atropine care
atropine sulfate drops, -ointment
3
1
1
1
3
3
3
1
1
1
QLL (30/365)
Page 74 of 117
azelastine hcl drops
Drug
BEPREVE
BOTOX
bromfenac sodium
cromolyn sodium drops
CYCLOGYL
cyclopentolate hcl drops
diclofenac sodium drops
ELESTAT
EMADINE
epinastine hcl
flurbiprofen sodium
homatropaire
ketorolac tromethamine drops
LACRISERT
LUCENTIS
mydral
naphazoline hcl drops
NATACYN
neofrin
NEVANAC
parcaine
PATANOL
phenylephrine hcl drops
proparacaine hcl drops
RESTASIS
tropicacyl
tropicamide drops
XIBROM
ZIRGAN
Tier
1
3
3
1
1
3
1
1
3
3
1
1
1
1
2
4
1
1
2
1
3
1
3
1
1
3
1
1
3
2
Restrictions
PA
RESPIRATORY MEDICATIONS
ANTIHISTAMINE/DECONGESTANT
COMBINATIONS
gripex pe
promethazine vc
SEMPREX-D
1
1
3
Page 75 of 117
ANTIHISTAMINES
Drug
arbinoxa
brompheniramine tannate
carbinoxamine maleate
clemastine fumarate syrup, -fum 2.68 mg tab
cyproheptadine hcl syrup, -tablet
dexchlorpheniramine maleate
diphenhydramine hcl capsule, -elixir, -injection
fexofenadine hcl
levocetirizine dihydrochloride
promethazine hcl injection, -syrup, -tablet
XYZAL
Tier
1
1
1
1
1
1
1
1
1
1
3
Restrictions
PA
PA
BETA-2 ADRENERGIC DRUGS
albuterol sulfate nebs, -solution non-oral, -syrup,
-tablet, -tablet sustained release 12hr
albuterol sulfate vial nebulizer
BROVANA
ephedrine 50 mg/ml ampul
FORADIL
LEVALBUTEROL CONCENTRATE
MAXAIR AUTOHALER
metaproterenol sulfate syrup, -tablet
PERFOROMIST
PROAIR HFA
PROVENTIL HFA
SEREVENT DISKUS
terbutaline sulfate injection, -tablet
VENTOLIN HFA
XOPENEX 0.31 MG/3 ML SOLUTION, -0.63 MG/3
ML SOLUTION
XOPENEX 1.25 MG/3 ML SOLUTION
XOPENEX CONCENTRATE
XOPENEX HFA
1
1
3
1
2
1
3
1
3
3
3
2
1
2
3
PA
PA
PA
PA
ST
ST
PA, ST
3
3
3
LEUKOTRIENE MODIFIERS
SINGULAIR
2
QLL (31/31)
Page 76 of 117
zafirlukast
Drug
ZYFLO CR
Tier
Restrictions
1
2
METHYL XANTHINE DRUGS
aminophylline injection, -tablet
ELIXOPHYLLIN
theochron
theophylline anhydrous tablet sustained release
12hr
theophylline tablet sustained action
1
2
1
1
1
OTHER DRUGS FOR ASTHMA
acetylcysteine vial
ADRENACLICK
ADRENALIN CHLORIDE SOLUTION NON-ORAL
ADVAIR DISKUS
ADVAIR HFA
ATROVENT HFA
budesonide ampul for nebulization
COMBIVENT
cromolyn sodium ampul for nebulization
DULERA
epinephrine 0.1 mg/ml syringe, -1 mg/ml ampul,
-1 mg/ml vial
EPIPEN
EPIPEN JR
FLOVENT DISKUS
FLOVENT HFA
GASTROCROM
ipratropium bromide solution non-oral
ipratropium-albuterol
QVAR
SPIRIVA
SYMBICORT
TWINJECT
XOLAIR
1
3
2
2
2
3
1
3
1
3
1
2
2
2
2
2
1
1
2
2
2
3
4
PA
PA
PA
PA
PA
PA, LTD
Page 77 of 117
Drug
Tier
OTHER RESPIRATORY DRUGS
ARALAST NP 1,000 MG VIAL
ARALAST NP 500 MG VIAL
DALIRESP
GLASSIA
PROLASTIN 1,000 MG VIAL
PROLASTIN 500 MG VIAL
PROLASTIN C
PULMOZYME
ZEMAIRA
4
4
3
4
4
4
4
4
4
Restrictions
PA, LTD
PA
PA
PA, LTD
PA, LTD
PA
PA, LTD
UROLOGICAL MEDICATIONS
ANTICHOLINERGIC ANTISPASMODICS
DETROL
DETROL LA
flavoxate hcl
GELNIQUE
oxybutynin chloride er
oxybutynin chloride syrup, -tablet
TOVIAZ
trospium chloride
VESICARE
2
2
1
3
1
1
2
1
2
CHOLINERGIC STIMULANTS
bethanechol chloride tablet
1
OTHER GENITOURINARY PRODUCTS
acetic acid 0.25% irrig soln
alfuzosin hcl
AVODART
CYSTADANE
cytra-k
ELMIRON
finasteride tablet
JALYN
neomy-polymyxin b 40 mg/ml amp
phenazopyridine plus
1
1
2
2
1
2
1
2
1
1
Page 78 of 117
Drug
phosphasal
potassium citrate TABLET SUSTAINED ACTION
potassium citrate-citric acid
tamsulosin hcl
taron-crystals
tricitrates
urin d.s.
Tier
Restrictions
1
1
1
1
1
1
1
Page 79 of 117
Index:
10 wash, 36
1ST TIER UNIFINE PENTIPS PLUS, 53
8-MOP, 37
ABELCET, 8
ABILIFY DISCMELT, 18
ABILIFY INJECTION, 18
ABILIFY SOLUTION, 18
ABILIFY TABLET, 18
ABRAXANE, 12
ABSTRAL, 21
acarbose, 43
acebutolol hcl capsule, 30
acetaminoph-caff-dihydrocodein, 22
acetaminophen-codeine, 22
acetaminophen-tramadol, 17
acetasol hc, 39
acetazolamide capsule sustained
action, -tablet, 72
acetazolamide sodium, 72
acetic acid 0.25% irrig soln, 78
acetic acid solution non-oral, 39
acetic acid-aluminum, 39
acetylcysteine vial, 77
ACID JELLY, 69
ACTEMRA 200 MG/10 ML VIAL, 51
ACTEMRA 80 MG/4 ML VIAL, -400
MG/20 ML VIAL, 51
ACTHIB, 48
acticin, 37
ACTIMMUNE, 51
ACTIVELLA 0.5-0.1 MG TABLET, 68
ACTONEL 150 MG TABLET, 43
ACTONEL 35 MG TABLET, 43
ACTONEL 5 MG TABLET, -30 MG
TABLET, 43
ACTOPLUS MET, 43
ACTOPLUS MET XR, 43
ACTOS, 43
ACUVAIL, 74
acyclovir capsule, -suspension oral, tablet, 7
acyclovir sodium, 7
ADACEL, 49
ADAGEN, 39
adapalene, 35
ADCIRCA, 34
ADRENACLICK, 77
ADRENALIN CHLORIDE SOLUTION
NON-ORAL, 77
adriamycin 10 mg vial, -20 mg vial, 50 mg vial, 12
adriamycin 2 mg/ml vial, 12
adrucil, 12
ADVAIR DISKUS, 77
ADVAIR HFA, 77
aero otic hc, 39
afeditab cr, 30
AFINITOR, 12
AGGRENOX, 59
A-HYDROCORT, 41
AIMSCO INS SYR 0.3 ML 29GX1/2, AIMSCO INS SYR 0.3 ML 30GX5/16,
-AIMSCO INS SYR 0.5 ML 28GX1/2,
-AIMSCO INS SYR 0.5 ML 29GX1/2,
-AIMSCO INS SYR 1 ML 28GX1/2, AIMSCO INS SYR 1 ML 29GX1/2, AIMSCO SYRING 0.3 ML 31GX5/16,
-AIMSCO SYRING 0.5 ML 30GX5/16,
-AIMSCO SYRING 0.5 ML 31GX5/16,
-BD INSULIN SYR 0.3 ML 28GX1/2, BD INSULIN SYR 0.3 ML 29GX1/2, BD INSULIN SYR 0.3 ML 30GX1/2, BD INSULIN SYR 0.3ML 31GX5/16, BD INSULIN SYR 0.5 ML 28GX1/2, BD INSULIN SYR 0.5 ML 29GX1/2, BD INSULIN SYR 0.5 ML 30GX1/2, BD INSULIN SYR 0.5ML 31GX5/16, BD INSULIN SYR 1 ML 25GX1, -BD
INSULIN SYR 1 ML 25GX5/8, -BD
INSULIN SYR 1 ML 26GX1/2, -BD
INSULIN SYR 1 ML 27GX5/8, -BD
INSULIN SYR 1 ML 28GX1/2, -BD
Page 80 of 117
INSULIN SYR 1 ML 29GX1/2, -BD
INSULIN SYR 1 ML 30GX1/2, -BD
INSULIN SYR 1 ML 31GX5/16, -BD
INSULIN SYRINGE 1 ML, -BD
INSULIN U100-3/10 ML SYR, FIFTY50 INSULIN SYRINGE 0.3 ML,
-FIFTY50 INSULIN SYRINGE 0.5 ML,
-FIFTY50 INSULIN SYRINGE 1 ML, INS SYR 0.3 ML 29GX1/2, -INS SYR
0.3 ML 30GX5/16, -INS SYR 0.5 ML
28GX1/2, -INS SYR 0.5 ML 29GX1/2,
-INS SYR 0.5 ML 30GX1/2, -INS SYR
0.5 ML 30GX5/16, -INS SYR 1 ML
28GX1/2, -INS SYR 1 ML 29GX1/2, INS SYR 1 ML 31GX5/16, -INS SYR
U100 1 ML 28GX1/2, -INS SYRIN 0.3
ML 30GX1/2, -INS SYRIN 1 ML
29GX1/2, -INS SYRING 0.3 ML
30GX5/16, -INS SYRINGE 1 ML
28GX1/2, -INS SYRINGE 3/10 ML, INSUL SYR 0.3 ML 31GX5/16, INSUL SYR 0.5 ML 28GX1/2, -INSUL
SYR 0.5 ML 30GX1/2, -INSUL SYR
0.5 ML 31GX5/16, -0.3 ML SYRINGE,
-0.5 ML SYRINGE, -1 ML SYRINGE, 1/2 ML SYRINGE, -3/10 ML
SYRINGE, -SYR 0.3 ML 29GX1/2, SYR 0.5 ML 28GX1/2, -SYR 1 ML
29GX1/2, -SYR 1 ML 30GX5/16, SYR 1 ML 31GX5/16, -SYRIN 0.3 ML
29GX1/2, -SYRIN 0.3 ML 30GX1/2, SYRIN 0.3 ML 30GX5/16, -SYRIN 0.3
ML 31GX5/16, -SYRIN 0.3 ML
31GX5/16, -SYRIN 0.5 ML 28GX1/2,
-SYRIN 0.5 ML 29GX1/2, -SYRIN 0.5
ML 30GX1/2, -SYRIN 0.5 ML
30GX5/16, -SYRIN 0.5 ML
30GX5/16, -SYRIN 0.5 ML
31GX5/16, -SYRIN 1 ML 29GX1/2, -1
ML 28GX1/2, -1 ML 29GX1/2, -1 ML
30GX1/2, -1 ML 31GX5/16, -1 ML-
HARD PK, -U100 0.5 ML, -U100 1
ML, -INSULN SYR, 52
AIMSCO INS SYR 1 ML 30GX5/16, CAREONE INS SYR 1 ML 30GX5/16,
-INS SYR 1 ML 30GX5/16, -INS
SYRINGE 1 ML 30GX1/2, -INS
SYRINGE 1 ML 30GX5/16, -1 ML
30GX5/16, -30GX1 ML SYR, PREFPLS INS SYR 1 ML 30GX5/16, RELION INS SYR 1 ML 30GX5/16, RELION INSULIN SYR 0.3 ML, RELION INSULIN SYR 0.5 ML, RELION INSULIN SYRINGE 1 ML, RELION SYRING 0.5 ML 31GX5/16, U100 1 ML 30GX5/16, -ULTCARE
INS SYR 1 ML 30GX5/16, WDMEDIC INS SYR 1 ML 30GX5/16,
53
AIMSCO MINI ULTRA-THIN II, 53
AIMSCO ULTRA THIN II, 53
ak-con, 74
ak-dilate 10% eye drops, 74
akorn balanced salt, 74
ak-poly-bac, 73
aktob, 73
ALAMAST, 74
ALBENZA, 2
albuterol sulfate nebs, -solution nonoral, -syrup, -tablet, -tablet
sustained release 12hr, 76
albuterol sulfate vial nebulizer, 76
alclometasone dipropionate, 37
alcohol in dextrose, 59
ALCOHOL PADS, 53
ALCOHOL PREP PADS, 53
ALCOHOL PREP SWABS, 53
ALCOHOL SWAB, 54
ALCOHOL SWABS, 54
ALCOHOL WIPES, 54
ALDARA, 38
ALDURAZYME, 44
alendronate sodium, 44
Page 81 of 117
alfuzosin hcl, 78
ALIMTA, 12
ALINIA, 6
ALKERAN INJECTION, 12
allopurinol sodium, 57
allopurinol tablet, 58
ALOCRIL, 74
ALOMIDE, 74
ALOXI, 19
ALREX, 73
altafrin, 74
altavera, 66
aluvea 40% cream, 38
amantadine, 7
AMBISOME, 8
amcinonide, 37
AMEBICIDES, 1
a-methapred 40 mg vial, 41
amethia, 66
amethyst, 66
AMEVIVE, 12
amifostine, 12
amikacin sulfate injection, 1
amiloride hcl tablet, 34
amiloride-hydrochlorothiazide, 34
aminocaproic acid injection, -solution
oral, -tablet, 39
AMINOGLYCOSIDES, 1
aminophylline injection, -tablet, 77
AMINOSYN, 60
AMINOSYN II, 60
AMINOSYN II 3.5% M-DEXTROSE 5%,
60
AMINOSYN II 3.5%-DEXTROSE 25%,
60
AMINOSYN II 3.5%-DEXTROSE 5%,
60
AMINOSYN II 4.25% M-DEXT 10%, 60
AMINOSYN II 4.25%-DEXTROSE 25%,
60
AMINOSYN II 5% IN 25% DEXTROSE,
60
AMINOSYN II IN DEXTROSE, 60
AMINOSYN II WITH LYTES-CA-DW, 60
AMINOSYN M, 60
AMINOSYN WITH ELECTROLYTES, 60
AMINOSYN-HBC, 60
AMINOSYN-HF, 60
AMINOSYN-PF, 60
AMINOSYN-RF, 60
amiodarone hcl injection, -tablet, 29
AMIODARONES, 29
AMITIZA, 46
amitriptyline hcl tablet, 28
amlodipine besylate tablet, 30
amlodipine besylate-benazepril, 33
AMMONIUM CHLORIDE INJECTION,
60
ammonium lactate cream, -lotion, 38
amnesteem, 37
amox tr-potassium clavulanate, 8
amoxapine, 27
amoxicillin, 9
amoxicillin-clavulanate er, 9
amphetamine salts 10 mg tab, 23
amphetamine salts 12.5 mg tb, 23
amphetamine salts 15 mg tab, 23
amphetamine salts 20 mg tab, 23
amphetamine salts 30 mg tab, 23
amphetamine salts 5 mg tab, 23
amphetamine salts 7.5 mg tab, 23
AMPHOTEC, 8
amphotericin b injection, 8
ampicillin sodium, 9
ampicillin trihydrate, 9
ampicillin-sulbactam, 9
AMPYRA, 39
AMTURNIDE, 33
ANADROL-50, 65
anagrelide hcl, 12
ANALGESICS, 17
anastrozole tablet, 12
ANCOBON, 5
ANDRODERM, 65
Page 82 of 117
ANDROGEL 1% GEL PUMP, -1%(2.5G)
GEL PACKET, 65
ANDROGEL 1.62% GEL PUMP, 1%(5G) GEL PACKET, 66
ANDROGEN DRUGS, 65
anestacon, 1
ANESTHETICS, 1
ANGELIQ, 68
ANGIOTENSIN CONVERTING ENZYME
INHIBITORS, 29
ANGIOTENSIN II RECEPTOR
ANTAGONISTS, 29
ANTABUSE, 26
ANTHELMINTICS, 2
ANTICHOLINERGIC
ANTISPASMODICS, 78
ANTIDEMENTIA DRUGS, 17
ANTIDIARRHEAL DRUGS, 45
ANTIDYSRHYTHMIC DRUGS, 29
ANTIGLAUCOMA DRUGS, 72
ANTIHISTAMINE/DECONGESTANT
COMBINATIONS, 75
ANTIHISTAMINES, 76
ANTIINFECTIVES, 1
ANTIINFECTIVES SPECIALIZED
INDICATIONS, 2
ANTIMANIA DRUGS, 18
ANTINEOPLASTIC/IMMUNOSUPPRESS
ANT DRUGS, 12
ANTIPARKINSON ANTICHOLINERGIC
DRUGS, 18
ANTIPLATELET DRUGS, 59
ANTIPRURITIC DRUGS, 36
ANTIPSORIASIS AND ANTIECZEMA
DRUGS, 36
ANTIPSYCHOTIC DRUGS, 18
antipyrine-benzocaine, 39
ANTIRETROVIRALS AND PROTEASE
INH, 2
ANTISPASMODICS/DRUGS AFFECT GI
MOTILITY, 45
ANTITHYROID DRUGS, 41
ANTITUBERCULOSIS DRUGS, 3
ANTIULCER DRUGS, 46
ANTIVERTIGO AND ANTIEMETIC
DRUGS, 19
ANXIOLYTICS, 20
ANZEMET 100 MG TABLET, 19
ANZEMET 50 MG TABLET, 19
ANZEMET INJECTION, 19
APIDRA, 42
APIDRA SOLOSTAR, 42
APOKYN, 26
apraclonidine hcl, 72
apri, 66
APRISO, 46
APTIVUS, 2
ARALAST NP 1,000 MG VIAL, 78
ARALAST NP 500 MG VIAL, 78
aranelle, 66
ARANESP 25 MCG/0.42 ML SYRING, 25 MCG/ML VIAL, -40 MCG/0.4 ML
SYRINGE, -40 MCG/ML VIAL, 49
ARANESP 60 MCG/0.3 ML SYRINGE, 60 MCG/ML VIAL, -100 MCG/0.5 ML
SYRINGE, -100 MCG/ML VIAL, -200
MCG/0.4 ML SYRINGE, -150
MCG/0.3 ML SYRINGE, -200
MCG/ML VIAL, -300 MCG/0.6 ML
SYRINGE, -300 MCG/ML VIAL, -500
MCG/1 ML SYRINGE, -150 MCG/0.75
ML VIAL, 49
arbinoxa, 76
ARCALYST, 51
ARISTOSPAN, 41
ARIXTRA 2.5 MG SYRINGE, 63
ARIXTRA 5 MG SYRINGE, -7.5 MG
SYRINGE, -10 MG SYRINGE, 63
ARMOUR THYROID, 45
AROMASIN, 12
ARRANON, 12
ARTHROTEC 50, 58
ARTHROTEC 75, 58
ASACOL, 46
Page 83 of 117
ASACOL HD, 46
ascomp with codeine, 24
ASTEPRO, 40
atamet, 26
ATELVIA, 44
atenolol tablet, 30
atenolol-chlorthalidone, 33
ATGAM, 49
atovaquone-proguanil hcl, 9
ATRIPLA, 2
atropine care, 74
atropine sulfate drops, -ointment, 74
atropine sulfate injection, 26
ATROVENT HFA, 77
ATTENUVAX VACCINE WITH DILUENT,
49
aurodex, 40
auroguard, 40
AURORA PEN NEEDLE 6MM 31G, AURORA PEN NEEDLES 12MM 29G,
-AURORA PEN NEEDLES 8MM 31G, BD PEN NEEDLE 29GX1/2, -BD PEN
NEEDLE 29GX3/16, -BD PEN
NEEDLE 29GX5/16, -BD PEN
NEEDLE MINI 31GX3/16, -BD PEN
NEEDLE NANO 32GX5/32, -BD PEN
NEEDLE ORIG 29GX1/2, -BD PEN
NEEDLE SHORT 31GX5/16, CLICKFINE PEN NDL 31GX1/4, CLICKFINE PEN NDL 31GX5/16, LIVE BETTER PEN NEEDLE 6MM
31G, -LIVE BETTER PEN NEEDLES
12MM, -LIVE BETTER PEN NEEDLES
8MM, -MS PEN NEEDLE 6MM 31G, 12MM 29G NEEDLES, -8MM 31G
NEEDLES, -31GX3/16, -31GX5/16, 6MM 31G, -S 12MM 29G, -S 29G, -S
31G, -S 31G X 5/16, -S 8MM 31G, TODAY'S HLT PN NEEDLE 12MM
29G, -TODAY'S HLTH PN NEEDLE
6MM 31G, -TODAY'S HLTH PN
NEEDLE 8MM 31G, -UNIFINE
PENTIP 6MM 31G, 54
AUTO INJECTOR, 54
AUTOJECT 2, 54
AUTONOMIC AND CNS MEDICATIONS,
17
AUTOPEN, 54
AVALIDE, 33
AVANDAMET, 43
AVANDARYL, 43
AVANDIA, 43
AVAPRO, 29
AVASTIN, 12
AVELOX, 10
AVELOX ABC PACK, 10
AVELOX IV, 10
aviane, 66
AVODART, 78
AVONEX, 51
AVONEX ADMINISTRATION PACK, 51
AZACTAM 1 GM VIAL, 6
AZACTAM-ISO-OSMOT 1 GM/50 ML, 6
AZACTAM-ISO-OSMOT 2 GM/50 ML, 6
AZASAN, 12
AZASITE, 73
AZATHIOPRINE SODIUM, 12
azathioprine tablet, 12
azelastine hcl aerosol spray w/pump,
40
azelastine hcl drops, 75
AZILECT, 26
azithromycin injection, -packet, suspension, -tablet, 8
AZOPT, 72
aztreonam, 6
azurette, 66
baciim, 6
bacitracin 500 unit/gm ointmnt, 73
bacitracin injection, 6
bacitracin-polymyxin, 73
baclofen tablet, 57
BACTROBAN NASAL, 11
Page 84 of 117
balsalazide disodium, 47
balziva, 66
BANZEL, 25
BARACLUDE SOLUTION, 7
BARACLUDE TABLET, 7
baycadron, 41
BCG VACCINE (TICE STRAIN), 49
BD LUER-LOK SYRINGE 1 ML, 54
BD SAFETYGLIDE SYRINGE 27GX5/8,
54
belladonna-opium, 21
benazepril hcl, 29
benazepril-hydrochlorothiazide, 33
BENICAR, 29
BENICAR HCT, 33
BENTYL INJECTION, 45
benzoyl peroxide 2.5% wash, -4.5%
cleanser, -5% wash, -5.75 % wash,
-6.5% cleanser, -8.5% cleanser, 10% wash, -gel, -4% lotion, -8%
lotion, 35
benztropine mesylate injection, -tablet,
18
BEPREVE, 75
BESIVANCE, 73
BETA-2 ADRENERGIC DRUGS, 76
BETA-ADRENERGIC ANTAGONIST
DRUGS, 30
betamethasone acetate-sod phos, 41
betamethasone dipropionate cream, gel, -lotion, -ointment, 37
betamethasone valerate cream, lotion, -ointment, 37
BETASERON, 51
beta-val, 37
betaxolol hcl drops, 72
betaxolol hcl tablet, 30
bethanechol chloride tablet, 78
BETIMOL, 72
BETOPTIC S, 72
bicalutamide, 12
BICILLIN C-R, 9
BICILLIN L-A, 9
BICNU, 12
BIDIL, 34
BILTRICIDE, 2
bisoprolol fumarate, 30
bisoprolol-hydrochlorothiazide, 33
bleomycin sulfate 15 unit vial, 12
bleomycin sulfate 30 unit vial, 12
BLEPHAMIDE, 73
BLEPHAMIDE S.O.P., 73
BLOOD DETOXICANTS, 59
BONIVA INJECTION, 44
BONIVA TABLET, 44
BOOSTRIX, 49
borofair, 40
BOTOX, 75
bp 10-1, 35
briellyn, 66
brimonidine tartrate, 72
bromfenac sodium, 75
bromocriptine mesylate capsule, tablet, 26
brompheniramine tannate, 76
BROVANA, 76
budeprion sr, 25
budeprion xl 150 mg tablet, 25
budeprion xl 300 mg tablet, 25
budesonide ampul for nebulization, 77
budesonide ec, 47
bumetanide, 32
BUPHENYL, 39
BUPRENORPHINE 0.3 MG/ML SYRN,
17
buprenorphine 0.3 mg/ml vial, 22
buprenorphine 2 mg tablet sl, 22
buprenorphine 8 mg tablet sl, 22
buproban, 28
bupropion hcl sr, 25
bupropion hcl tablet, 25
bupropion xl, 25
buspirone hcl tablet, 20
BUSULFEX, 12
Page 85 of 117
butalb-caff-acetaminoph-codein, 24
butalbital compound-codeine, 24
butorphanol tartrate aerosol spray, 24
butorphanol tartrate injection, 17
BYETTA, 42
BYSTOLIC, 30
cabergoline, 44
CADUET, 31
cafgesic forte, 57
calcipotriene, 36
calcitonin-salmon, 44
calcitriol 1 mcg/ml vial, 64
calcitriol capsule, -1 mcg/ml ampul, -2
mcg/ml vial, -solution, 64
calcium acetate capsule, 65
CALCIUM ANTAGONISTS, 30
calcium gluconate injection, 60
camila, 71
CAMPATH, 12
CAMPRAL, 26
camrese, 66
CANASA, 47
CANCIDAS, 8
CANTIL, 45
CAPASTAT SULFATE, 3
CAPRELSA 100 MG TABLET, 12
CAPRELSA 300 MG TABLET, 12
captopril tablet, 29
captopril-hydrochlorothiazide, 33
CARAC, 38
CARAFATE SUSPENSION ORAL, 46
carbamazepine capsule sustained
action, -suspension oral, -tablet, tablet chewable, 20
carbamazepine xr, 20
CARBAMAZEPINES, 20
CARBATROL, 20
carbidopa-levodopa, 26
carbinoxamine maleate, 76
carboplatin 150 mg/15 ml vial, 12
carboplatin 450 mg/45 ml vial, -50
mg/5 ml vial, -600 mg/60 ml vial, -
50 mg vial, -150 mg vial, -450 mg
vial, 12
CARDIAC GLYCOSIDES, 31
CARDIOVASCULAR MEDICATIONS, 29
CARDURA XL, 35
CARIMUNE NF NANOFILTERED, 49
carisoprodol 350 mg tablet, 57
carisoprodol compound, 57
carisoprodol compound-codeine, 57
carisoprodol-aspirin, 57
CARNITOR INJECTION, 65
carteolol hcl, 72
cartia xt, 30
carvedilol, 30
CATAPRES-TTS 1, 31
CATAPRES-TTS 2, 31
CATAPRES-TTS 3, 31
cavan one omega, 69
cavan-folate ob, 69
cavan-heme ob, 69
cavan-heme omega, 69
CAYSTON, 6
caziant, 66
CEDAX, 4
CEENU, 12
cefaclor, 4
cefaclor er, 4
cefadroxil, 4
cefazolin 20 gm bulk vial, -500 mg
vial, -1 gm add-van vial, -1 gm vial,
-1 gm-d5w bag, -10 gm vial, 4
cefazolin sod 100 gm bulk bag, -sod
300 gm bulk bag, 4
cefdinir, 4
CEFDITOREN PIVOXIL 400 MG TAB, 4
cefepime hcl, 4
cefotaxime sodium, 4
cefotetan, 4
cefoxitin, 4
cefoxitin sodium, 4
cefpodoxime proxetil, 4
cefprozil, 4
Page 86 of 117
ceftazidime 500 mg vial, 4
ceftriaxone, 4
cefuroxime, 4
cefuroxime axetil, 4
CEFUROXIME SOD 75 GM BULK BAG,
4
cefuroxime sod 750 mg vial, -sod 1.5
gm vial, -sod 7.5 gm vial, 4
CELEBREX, 58
CELESTONE, 41
CELLCEPT INJECTION, 12
CELLCEPT SUSPENSION
RECONSTITUTED ORAL, 12
CELONTIN, 28
CENESTIN, 68
CENTRALLY ACTING
ANTIHYPERTENSIVES, 31
cephalexin, 4
CEPHALOSPORINS, 4
CEREBYX, 24
CEREDASE, 44
CEREZYME 200 UNITS VIAL, 44
CEREZYME 400 UNITS VIAL, 44
CERVARIX, 49
cesia, 66
CHANTIX TABLET, 28
CHANTIX TABLET DOSE PACK, 28
CHEMET, 39
chloral hydrate syrup, 27
chloramphenicol sod succinate, 5
CHLORAMPHENICOLS, 5
chlordiazepoxide-amitriptyline, 25
CHLORHEXIDINE GLUC 20% SOLN, 11
chlorhexidine gluconate mouthwash,
40
chloroquine phosphate tablet, 9
chlorothiazide, 35
chlorothiazide sodium, 35
chloroxylenol-pramoxine hcl, 40
chlorphenylcaine, 40
chlorpromazine hcl injection, -tablet,
18
chlorpropamide, 43
chlorthalidone, 35
chlorzoxazone, 57
cholestyramine, 32
cholestyramine light, 32
choline mag trisalicylate, 59
CHOLINERGIC STIMULANTS, 78
chorionic gonadotropin injection, 71
ciclopirox cream, -gel, -solution nonoral, -suspension topical, 8
cilostazol, 59
CILOXAN OINTMENT, 73
cimetidine injection, -solution, -tablet,
46
CIMZIA 200 MG VIAL KIT, -200 MG/ML
SYRINGE KIT, 12
CINRYZE, 49
CIPRO HC, 40
CIPRODEX, 40
ciprofloxacin, 10
ciprofloxacin er 1,000 mg tab, 10
ciprofloxacin er 500 mg tablet, 10
ciprofloxacin hcl drops, 74
ciprofloxacin hcl tablet, 10
ciprofloxacin-d5w, 10
cisplatin, 12
citalopram, 27
citalopram hbr, 27
cladribine, 12
claravis, 37
clarithromycin er, 8
clarithromycin suspension, -tablet, 8
CLASS II NARCOTICS, 21
CLASS III NARCOTICS, 22
CLASS IV NARCOTICS, 22
clemastine fumarate syrup, -fum 2.68
mg tab, 76
CLEOCIN HCL 75 MG CAPSULE, 5
CLEOCIN PALMITATE, 5
CLEOCIN PHOSPHATE IN D5W, 5
CLEOCIN SUPPOSITORY VAGINAL, 69
CLICKFINE, 54
Page 87 of 117
CLIMARA PRO, 68
clindacin p, 35
clindamycin hcl capsule, 5
clindamycin palmitate hcl, 5
clindamycin phosphate cream with
applicator, 69
clindamycin phosphate gel, -lotion, solution non-oral, -swab medicated,
35
clindamycin phosphate injection, 5
clindamycin-benzoyl peroxide, 35
CLINDAMYCINS, 5
CLINIMIX, 60
CLINIMIX E 2.75%-10% SOLUTION, 2.75%-5% SOLUTION, -4.25%-25%
SOLUTION, -4.25%-5% SOLUTION,
-5%-15% SOLUTION, -5%-20%
SOLUTION, -5%-25% SOLUTION,
60
CLINISOL, 60
clobetasol emollient, 37
clobetasol propionate cream, -gel, ointment, -solution non-oral, 37
CLOLAR, 12
clomipramine hcl capsule, 28
clonidine, 31
clonidine hcl injection, -tablet, 31
CLORPRES, 33
clotrimazole cream, -solution non-oral,
8
clotrimazole troche, 5
clotrimazole-betamethasone, 11
clozapine, 18
CNS MUSCLE RELAXANTS, 57
CNS STIMULANT DRUGS, 23
COARTEM, 9
codeine phosphate injection, 21
codeine sulfate, 21
COGENTIN, 18
co-gesic, 22
COGNEX, 17
COLCRYS, 58
colestipol hcl, 32
colistimethate 150 mg vial, 6
COLOCORT, 47
COLY-MYCIN S, 40
COLYTE WITH FLAVOR PACKETS, 47
COLYTE WITH FLAVOR PACKS, 47
COMBIGAN, 72
COMBIPATCH, 68
COMBIVENT, 77
COMBIVIR, 2
compro, 19
COMTAN, 26
COMVAX, 49
co-natal fa, 69
CONCERTA ER 18 MG TABLET, -ER 27
MG TABLET, -ER 54 MG TABLET, 23
CONCERTA ER 36 MG TABLET, 23
CONDYLOX GEL, 36
constulose, 59
CONTRACEPTIVES, 66
COPAXONE, 39
COPEGUS, 7
COREG CR, 30
corenate-dha, 69
CORTIFOAM, 47
cortisone acetate tablet, 41
CORTISPORIN-TC, 40
cortomycin, 40
COSMEGEN, 13
CREON, 47
CRESYLATE, 40
CRIXIVAN, 2
cromolyn sodium ampul for
nebulization, 77
cromolyn sodium drops, 75
cryselle, 66
CUBICIN, 6
CUPRIMINE, 59
CURAD GAUZE PADS, 54
CURITY ALCOHOL PREPS, 54
CURITY SPONGE, 54
cyclafem, 66
Page 88 of 117
cyclobenzaprine 5 mg tablet, -10 mg
tablet, 57
CYCLOGYL, 75
cyclopentolate hcl drops, 75
cyclophosphamide injection, 13
cyclophosphamide tablet, 13
cyclosporine capsule, -injection, solution, 13
cyclosporine modified, 13
cyclosporine unit, 13
CYKLOKAPRON, 39
CYMBALTA 20 MG CAPSULE, 25
CYMBALTA 30 MG CAPSULE, -60 MG
CAPSULE, 25
cyproheptadine hcl syrup, -tablet, 76
CYSTADANE, 78
CYSTAGON, 60
cytarabine 100 mg vial, -1 gm vial, -2
gm vial, 13
cytarabine 20 mg/ml vial, -100 mg/ml
vial, -500 mg vial, 13
cytra-k, 78
d5w/kcl 10 meq/l iv solution, -d5w-kcl
30 meq/l iv solution, 60
dacarbazine 100 mg vial, 13
dacarbazine 200 mg vial, 13
DACOGEN, 13
dactinomycin, 13
DALIRESP, 78
d-amphetamine er 10 mg capsule, -10
mg tab, 23
d-amphetamine er 15 mg capsule, 23
d-amphetamine er 5 mg capsule, 23
danazol capsule, 66
dantrolene sodium capsule, 57
DAPSONE TABLET, 2
DAPTACEL, 49
DARAPRIM, 9
daunorubicin hcl, 13
DAUNOXOME, 13
DECAVAC, 49
DELESTROGEN, 68
delflex with 1.5% dextrose, 60
delflex with 2.5% dextrose, 60
delflex with 4.25% dextrose, 60
demeclocycline hcl, 10
DEMEROL 75 MG/ML SYRINGE, 21
DEMSER, 31
DENAVIR, 7
DEPACON, 28
depade, 26
DEPEN, 59
DEPO-ESTRADIOL, 68
DEPO-MEDROL 20 MG/ML VIAL, 41
DEPO-PROVERA 400 MG/ML VIAL, 13
DEPO-SUBQ PROVERA 104, 71
DERMATOLOGICAL MEDICATIONS, 35
DERMOTIC, 40
desipramine hcl tablet, 27
desmopressin acetate aerosol spray
w/pump, -injection, -solution, tablet, 44
desonide cream, -lotion, -ointment, 37
desoximetasone cream, -gel, ointment, 37
DETROL, 78
DETROL LA, 78
dexamethasone elixir, -solution oral, tablet, 41
dexamethasone intensol, 41
dexamethasone sodium phosphate
drops, 73
dexamethasone sodium phosphate
injection, 41
dexasporin, 73
dexchlorpheniramine maleate, 76
DEXILANT, 48
dexmethylphenidate 10 mg tab, 23
dexmethylphenidate 2.5 mg tab, 23
dexmethylphenidate 5 mg tab, 23
dexrazoxane 250 mg vial, 13
dexrazoxane 500 mg vial, 13
dextroamphetamine 5 mg tab, 23
dextroamphetamine-amphetamine, 23
Page 89 of 117
dextrose 10%-1/4ns, 60
dextrose 10%-1/4ns-kcl, 60
dextrose 5%-1/2ns-kcl, 60
dextrose 5%-1/3ns-kcl, 60
dextrose 5%-1/4ns-kcl, 60
dextrose 5%-electrolyte #48, 60
dextrose 5%-ns-kcl, 60
dextrose in lactated ringers, 64
dextrose in ringers injection, 60
dextrose in water, 60
dextrose with sodium chloride, 60
DIABETIC SUPPLIES, 52
DIAGNOSTIC AND MISCELLANEOUS
MEDICATIONS, 39
DIAGNOSTIC PRODUCTS, 39
DIANEAL PD-2 W-1.5% DEXTROSE, 61
DIANEAL PD-2 W-2.5% DEXTROSE, 61
DIANEAL PD-2 W-4.25% DEXTROSE,
61
DIANEAL WITH 1.5% DEXTROSE, 61
DIANEAL WITH 2.5% DEXTROSE, 61
DIANEAL WITH 4.25% DEXTROSE, 61
DIBENZYLINE, 31
diclofenac potassium, 58
diclofenac sodium drops, 75
diclofenac sodium tablet enteric
coated, -tablet sustained release
24hr, 58
dicloxacillin sodium, 9
dicyclomine hcl capsule, -injection, syrup, -tablet, 45
didanosine, 2
DIFICID, 6
diflorasone diacetate, 37
diflunisal tablet, 59
digoxin injection, -solution, -tablet, 31
dihydroergotamine mesylate injection,
24
DILANTIN 30 MG CAPSULE, -TABLET
CHEWABLE, 24
DILATRATE-SR, 32
dilt-cd, 30
diltiazem 24hr er, 30
diltiazem er, 30
diltiazem hcl injection, -tablet, 30
dilt-xr, 30
diltzac er, 30
diluent for epoprostenol vial, 34
DIOVAN, 29
DIOVAN HCT, 33
DIPENTUM, 47
DIPEPTIDYL PEPTIDASE-IV INHIB
AND COMBOS, 41
diphenhydramine hcl capsule, -elixir, injection, 76
diphenoxylate-atropine, 45
DIPHTHERIA-TETANUS TOXOID, 49
dipyridamole tablet, 59
DIRECT MUSCLE RELAXANTS, 57
diskets, 21
disopyramide phosphate, 29
disulfiram tablet, 26
DIURIL, 35
DIURIL SODIUM, 35
divalproex sodium, 28
divalproex sodium er, 28
DIVIGEL, 68
docetaxel 80 mg/8 ml vial, 13
donepezil hcl, 17
DORIBAX 500 MG VIAL, 6
dorzolamide hcl, 72
dorzolamide-timolol, 72
DOVONEX CREAM, 36
doxazosin mesylate, 35
doxepin hcl capsule, -solution, 28
DOXIL, 13
doxorubicin 10 mg/5 ml vial, -20
mg/10 ml vial, -50 mg/25 ml vial, 10 mg vial, -50 mg vial, 13
doxorubicin 200 mg/100 ml vial, 13
doxycycline, 10
doxycycline hyclate 20 mg tab, 40
doxycycline hyclate capsule, -hyc dr 75
mg cap, -injection, -100 mg tab, 10
Page 90 of 117
doxycycline mono 50 mg cap, -mono
100 mg cap, -tablet, 10
dronabinol 2.5 mg capsule, 19
DRONABINOL 5 MG CAPSULE, -10 MG
CAPSULE, 19
DROXIA, 13
DRUG MART ULTRA COMFORT SYR, -1
ML 30GX5/16, -1 ML SYRINGE, 54
DRUGS AFFECTING THE EAR, 39
DRUGS AFFECTING THE NOSE, 40
DRUGS AFFECTING THE THROAT AND
MOUTH, 40
DRUGS FOR PHEOCHROMOCYTOMA,
31
DRUGS TO PREVENT AND TREAT
GOUT, 57
DRUGS TO PREVENT AND TREAT
HEADACHES, 24
dualvit ob, 69
DUETACT, 43
DULERA, 77
DURACLON, 31
DURASAL, 36
DUREZOL, 73
DYRENIUM, 34
DYSPORT, 57
EAR-NOSE-THROAT MEDICATIONS, 39
EASY COMFORT 0.3 ML SYRINGE, COMFORT 0.5 ML SYRINGE, 54
EASY COMFORT INSULIN 1 ML SYR,
54
EASY TOUCH INSULIN SYR 1 ML, 54
EASY TOUCH NEEDLE DISPOSABLE, INSULIN SYR 0.3 ML, -INSULIN SYR
0.5 ML, 54
econazole nitrate cream, 8
ed k+10, 64
EDECRIN, 32
edge ob, 69
ed-spaz, 45
EDURANT, 2
EFFER-K 10 MEQ TABLET EFF, -20
MEQ TABLET EFF, 64
EFFIENT, 59
EGRIFTA, 48
ELAPRASE, 44
ELECTROLYTES, IRRIGATING
SOLUTIONS, ETC., 59
ELESTAT, 75
ELESTRIN, 68
ELIDEL, 38
ELIGARD 22.5 MG SYRINGE, 13
ELIGARD 30 MG SYRINGE, 13
ELIGARD 45 MG SYRINGE, 13
ELIGARD 7.5 MG SYRINGE, 13
eliphos, 65
ELITEK, 13
elite-ob 400, 69
ELIXOPHYLLIN, 77
ELLENCE, 13
ELMIRON, 78
ELOXATIN, 13
ELSPAR, 13
EMADINE, 75
EMCYT, 13
EMEND 125 MG CAPSULE, 20
EMEND 40 MG CAPSULE, 20
EMEND 80 MG CAPSULE, 20
EMEND INJECTION, 20
EMEND TRIFOLD PACK, 20
emoquette, 66
EMSAM, 24
EMTRIVA, 2
enalapril maleate tablet, 29
enalapril-hydrochlorothiazide, 33
ENBREL 25 MG KIT, -25 MG/0.5 ML
SYRINGE, -50 MG/ML SYRINGE, 13
ENBREL 50 MG/ML SURECLICK SYR,
13
endocet, 21
ENDOCRINE MEDICATIONS, 41
endodan, 21
Page 91 of 117
ENDOTHELIN RECPTR ANTAGONIST,
31
ENGERIX-B 10 MCG/0.5 ML PED VL, 10 MCG/0.5 ML SYRN, -20 MCG/ML
SYRINGE, -20 MCG/ML VIAL, 49
ENGERIX-B 10 MCG/0.5 ML PEDI, 49
ENJUVIA, 68
enoxaparin 30 mg/0.3 ml syr, -40
mg/0.4 ml syr, -60 mg/0.6 ml syr,
63
ENOXAPARIN 80 MG/0.8 ML SYR, -100
MG/ML SYR, -120 MG/0.8 ML SYR, 150 MG/ML SYR, 63
enpresse, 66
ENTOCORT EC, 47
enulose, 59
ephedrine 50 mg/ml ampul, 76
epiflur 0.5 mg tablet chewable, -1 mg
tablet chewable, 62
epiklor, 64
epinastine hcl, 75
epinephrine 0.1 mg/ml syringe, -1
mg/ml ampul, -1 mg/ml vial, 77
EPIPEN, 77
EPIPEN JR, 77
epirubicin 200 mg/100 ml vial, -50 mg
vial, -150 mg/75 ml vial, -200 mg
vial, 13
epirubicin 50 mg/25 ml vial, 13
epitol, 20
EPIVIR, 3
EPIVIR HBV, 7
eplerenone, 34
EPOGEN 10,000 UNITS/ML VIAL, 20,000 UNITS/2 ML VIAL, -20,000
UNITS/ML VIAL, -40,000 UNITS/ML
VIAL, 49
EPOGEN 2,000 UNITS/ML VIAL, -3,000
UNITS/ML VIAL, -4,000 UNITS/ML
VIAL, 49
epoprostenol sodium, 34
EPZICOM, 3
EQUETRO, 20
ERAXIS (WATER DILUENT), 8
ERBITUX, 13
ergoloid mesylates tablet, 39
ergotamine-caffeine, 24
errin, 71
ery, 35
ERYPED 200, 5
ERYPED 400, 5
ERY-TAB, 5
ERYTHROCIN LACTOBIONATE, 5
erythrocin stearate, 5
erythromycin capsule enteric coated, tablet, 5
erythromycin ethylsuccinate tablet, 5
erythromycin gel, -solution non-oral, swab medicated, 35
erythromycin ointment, 74
erythromycin-benzoyl peroxide, 35
ERYTHROMYCINS, 5
erythromycin-sulfisoxazole, 10
ESTRACE CREAM WITH APPLICATOR,
68
estradiol patch transdermal weekly, 68
estradiol tablet, 68
estradiol valerate injection, 68
estradiol-norethindrone acetat, 68
ESTRASORB, 68
ESTRING, 68
ESTROGEN DRUGS, 68
ESTROGEN/PROGESTIN
COMBINATIONS, 68
estropipate, 68
ethambutol hcl, 3
ethosuximide capsule, -syrup, 28
ETHYOL, 14
etidronate disodium, 44
etodolac, 58
ETOPOPHOS, 14
etoposide injection, 14
EVAMIST, 68
EVISTA, 44
Page 92 of 117
EVOXAC, 40
EXEL INSULIN SYRINGE, 54
EXELON PATCH TRANSDERMAL 24
HOURS, 17
EXELON SOLUTION, 17
exemestane, 14
EXFORGE, 33
EXFORGE HCT, 33
EXJADE, 39
EXTAVIA, 51
FABRAZYME 35 MG VIAL, 44
FABRAZYME 5 MG VIAL, 44
FACTIVE, 10
famciclovir, 7
famotidine injection, -suspension oral,
-20 mg tablet, -40 mg tablet, 46
FANAPT TABLET, 18
FANAPT TABLET DOSE PACK, 18
FARESTON, 14
FASLODEX, 14
FAZACLO, 18
felbamate, 25
FELBATOL, 25
felodipine er, 30
FEMARA, 14
FEMHRT 1/5 TABLET, 68
FEMRING, 68
FEMTRACE 0.45 MG TABLET, -0.9 MG
TABLET, 68
fenofibrate, 32
fenoprofen calcium tablet, 58
fentanyl 100 mcg/hr patch, 21
fentanyl 12 mcg/hr patch, -25 mcg/hr
patch, -50 mcg/hr patch, -75 mcg/hr
patch, 21
fentanyl citrate injection, 21
fentanyl citrate lozenge, 21
fexofenadine hcl, 76
finasteride tablet, 78
FIRMAGON 2 X 120 MG VIALS, 14
FIRMAGON 80 MG VIAL, 14
FIRST-TESTOSTERONE, 66
FIRST-TESTOSTERONE MC, 66
FLAGYL ER, 2
flavoxate hcl, 78
flecainide acetate, 29
FLOVENT DISKUS, 77
FLOVENT HFA, 77
floxuridine, 14
fluconazole in dextrose, 8
fluconazole in saline, 8
fluconazole suspension, -tablet, 5
FLUDARABINE 50 MG VIAL, 14
fludarabine 50 mg/2 ml vial, 14
fludrocortisone acetate tablet, 42
flunisolide aerosol spray, 40
fluocinolone acetonide cream, ointment, -solution non-oral, 37
fluocinonide cream, -gel, -ointment, solution non-oral, 37
fluocinonide emollient, 37
fluocinonide-e, 38
fluor-a-day 0.5 mg tab chew, -1 mg
tablet chew, 62
fluoride 0.5 mg chew tablet, -1 mg
chew tablet, 62
FLUORIDE PRODUCTS, 62
fluoritab tablet chewable, 62
fluorometholone suspension drops, 73
FLUOROPLEX, 38
fluorouracil cream, -solution non-oral,
38
fluorouracil injection, 14
fluoxetine hcl capsule, -solution, tablet, 27
fluphenazine decanoate, 18
fluphenazine hcl, 18
flurbiprofen sodium, 75
flurbiprofen tablet, 58
flutamide, 14
fluticasone propionate cream, ointment, 38
fluticasone propionate nasal inhaled
steroids, 40
Page 93 of 117
fluvoxamine maleate, 27
FML FORTE, 73
FML S.O.P., 73
folcal dha, 69
folcaps omega-3, 69
fomepizole, 39
fondaparinux 2.5 mg/0.5 ml syr, 63
fondaparinux 5 mg/0.4 ml syr, -7.5
mg/0.6 ml syr, -10 mg/0.8 ml syr,
63
FORADIL, 76
FORTAMET, 43
FORTAZ 500 MG VIAL, 4
FORTAZ IN ISO-OSMOTIC DEXTROSE,
5
FORTEO, 44
fortical, 44
foscarnet sodium, 7
fosinopril sodium, 29
fosinopril-hydrochlorothiazide, 33
fosphenytoin sodium, 24
FOSRENOL, 59
FRAGMIN 2,500 UNITS SYRINGE, 5,000 UNITS SYRINGE, 63
FRAGMIN 7,500 UNITS SYRINGE, 10,000 UNITS SYRINGE, -12,500
UNITS SYRINGE, -15,000 UNITS
SYRINGE, -18,000 UNITS SYRINGE,
-25,000 UNITS/ML VIAL, 63
FREAMINE HBC, 61
FREAMINE III, 61
FREAMINE III WITH ELECTROLYTES,
61
FREESTYLE PREC 0.5 ML 30GX5/16, PREC 0.5 ML 31GX5/16, -PREC 1 ML
31GX5/16, 54
FREESTYLE PREC 1 ML 30GX5/16, 54
fudr, 14
FURADANTIN, 11
furosemide injection, -solution, -tablet,
32
FUZEON, 3
gabapentin capsule, -solution, -tablet,
25
GABITRIL, 25
GABLOFEN, 57
galantamine hbr, 17
galantamine hydrobromide, 18
GAMASTAN S-D, 49
GAMMAGARD LIQUID, 49
GAMMAGARD S-D, 49
GAMMAPLEX, 49
GAMUNEX, 49
GAMUNEX-C, 49
ganciclovir, 7
ganciclovir sodium, 7
garamycin drops, 74
GARDASIL SYRINGE, 49
GARDASIL VIAL, 49
GASTROCROM, 77
GASTROINTESTINAL MEDICATIONS,
45
gavilyte-c, 47
gavilyte-g, 47
gavilyte-n, 47
GELNIQUE, 78
gemcitabine hcl, 14
gemfibrozil tablet, 32
GEMZAR, 14
generlac, 59
gengraf, 14
GENOTROPIN MINIQUICK 0.2 MG, 48
GENOTROPIN MINIQUICK 0.4 MG, MINIQUICK 0.6 MG, -MINIQUICK
0.8 MG, -MINIQUICK 1 MG, MINIQUICK 1.2 MG, -MINIQUICK
1.4 MG, -MINIQUICK 1.6 MG, MINIQUICK 1.8 MG, -MINIQUICK 2
MG, -5 MG CARTRIDGE, -12 MG
CARTRIDGE, 48
gentak, 74
GENTAMICIN 60 MG/NS 100 ML PB, ISOTON GENTAMICIN 60 MG/100
ML, -80 MG/NS 100 ML PB, -ISOTON
Page 94 of 117
GENTAMICIN 80 MG/100 ML, -ISO
GENTAMICIN 120 MG/100 ML, 2
gentamicin 90 mg/ns 100 ml pb, -100
mg/ns 100 ml, -iso gentamicin 100
mg/100 ml, -60 mg/ns 50 ml pb, isoton gentamicin 60 mg/50 ml, -70
mg/ns 50 ml pb, -80 mg/ns 50 ml
pb, -isoton gentamicin 80 mg/50 ml,
2
gentamicin sulfate cream, -0.1%
ointment, 11
gentamicin sulfate drops, -3 mg/gm
eye oint, 74
gentamicin sulfate injection, 2
gentasol, 74
GEODON CAPSULE, 18
GEODON INJECTION, 18
gianvi, 66
gildess fe, 66
GILENYA, 39
GLASSIA, 78
GLEEVEC 100 MG TABLET, 14
GLEEVEC 400 MG TABLET, 14
glimepiride, 43
glipizide er, 43
glipizide tablet, 43
glipizide xl, 43
glipizide-metformin, 43
GLUCAGEN, 42
GLUCAGON EMERGENCY KIT, 42
GLUCOCORTICOID DRUGS, 41
GLUCOPRO INSUL SYR U100 0.3 ML, INSUL SYR U100 0.5 ML, -INSULIN
SYR 0.5 ML, -INSULIN SYR 1 ML, U100 INSUL SYR 0.3 ML, 55
GLUCOPRO INSULIN SYR U100 1 ML, SYRINGE U100 1 ML, 55
GLUCOSE ELEVATING DRUGS, 42
glyburide micronized, 43
glyburide tablet, 43
glyburide-metformin hcl, 43
glycopyrrolate injection, -tablet, 45
glycron, 43
GLYSET, 43
GRALISE, 25
granisetron hcl 0.1 mg/ml vial, 20
granisetron hcl 1 mg/ml vial, -4 mg/4
ml vial, 20
granisetron hcl tablet, 20
granisol, 20
GRIFULVIN V, 5
gripex pe, 75
griseofulvin suspension oral, 5
GRIS-PEG, 5
GROWTH HORMONES AND RELATED
DRUGS, 48
guanabenz acetate tablet, 31
guanfacine hcl, 31
guanidine hcl, 27
GYNODIOL, 68
HALAVEN, 14
HALFLYTELY-BISACODYL, 47
halobetasol propionate, 38
haloperidol dec 50 mg/ml vial, -dec
100 mg/ml vial, 18
haloperidol decanoate 100, 18
haloperidol lactate, 18
haloperidol tablet, 18
HAVRIX, 49
heather, 71
HECTOROL 2 MCG/ML VIAL, -4 MCG/2
ML VIAL, 65
HECTOROL CAPSULE, -4 MCG/2 ML
AMPUL, 65
HELIDAC, 47
heparin lock flush 100 unit/ml, 63
heparin sod 1,000 unit/ml vial, -sod
2,000 unit/ml vial, -sod 2,500
unit/ml vial, -sod 5,000 unit/ml vial,
-sod 10,000 unit/ml vl, -sod 20,000
unit/ml vl, 63
heparin sod 5,000 unit/ml syr, -sod
5,000 unit/ 0.5 ml, -sod 5,000
unit/0.5 ml, 63
Page 95 of 117
heparin sodium in 0.45% nacl, 63
heparin-d5w 20,000 unit/500 ml, 63
heparin-d5w 25,000 unit/500 ml, -d5w 10,000 unit/100 ml, --d5w
25,000 unit/250 ml, 63
heparin-ns 1,000 unit/500 ml, 63
heparin-ns 2,000 unit/1,000 ml, 63
HEPATAMINE, 61
HEPATASOL, 61
HEPSERA, 7
HERCEPTIN, 14
HEXALEN, 14
HIZENTRA 1 GRAM/5 ML VIAL, 49
HIZENTRA 2 GRAM/10 ML VIAL, -4
GRAM/20 ML VIAL, 49
HMG-COA REDUCTASE INHIBITORS,
31
homatropaire, 75
HORIZANT, 25
HUMALOG, 42
HUMALOG MIX 50-50, 42
HUMALOG MIX 75-25, 42
HUMAPEN LUXURA HD, 55
HUMAPEN MEMOIR, 55
HUMATROPE, 48
HUMIRA, 14
HUMULIN 70-30, 42
HUMULIN N, 42
HUMULIN R, 42
HYCAMTIN INJECTION, 14
HYDANTOINS, 24
hydralazine hcl, 35
hydrochlorothiazide capsule, -tablet,
35
hydrocodone bit-ibuprofen, 22
hydrocodone-acetaminophen solution,
-hydrocodon-acetaminoph 2.5-500, hydrocodon-acetaminophen 5-325, hydrocodon-acetaminophen 5-500, hydrocodon-acetaminoph 7.5-325, hydrocodon-acetaminoph 7.5-750, hydrocodon-acetaminophn 10-650, -
hydrocodon-acetaminophn 10-325, hydrocodon-acetaminoph 7.5-500, hydrocodon-acetaminophn 10-500, hydrocodon-acetaminoph 7.5-650, hydrocodon-acetaminophn 10-660, hydrocodon-acetaminophn 10-750,
22
hydrocortisone 1% cream, -plus 1%
cream, --aloe 1% cream, -2.5%
cream, -lotion, -1% absorbase, -1%
oint, -1% ointment, -2.5%
ointment, 38
hydrocortisone acetate, 38
hydrocortisone butyrate, 38
hydrocortisone enema, 47
hydrocortisone tablet, 41
hydrocortisone valerate, 38
hydrocortisone-acetic acid, 40
hydromorphone hcl 1 mg/ml amp, -1
mg/ml syringe, -2 mg/ml syringe, -2
mg/ml vial, -2 mg/ml amp, -2 mg/ml
vl, -4 mg/ml syrin, -10 mg/ml vial, 50 mg/5 ml vial, -500 mg/50 ml via,
-10 mg/ml amp, -suppository rectal,
-tablet, 21
hydroxychloroquine sulfate tablet, 9
hydroxyurea capsule, 14
hydroxyzine hcl injection, -syrup, tablet, 36
hydroxyzine pamoate capsule, 36
hyomax, 45
hyoscyamine sulfate drops, -elixir, tablet, -tablet dispersible lingual, tablet sublingual, -tablet sustained
release 12hr, 45
hypercare, 38
HYPOGLYCEMIC DRUGS, 42
HYPOLIPOPROTEINEMICS, 32
ibuprofen suspension oral, -400 mg
tablet, -600 mg tablet, -800 mg
tablet, 58
ibutilide fumarate, 33
Page 96 of 117
IDAMYCIN PFS, 14
idarubicin hcl, 14
ifosfamide, 14
ifosfamide-mesna, 14
ILARIS, 51
imipramine hcl tablet, 28
imipramine pamoate, 28
imiquimod cream, 38
IMMUNOLOGICALS AND VACCINES, 48
IMOVAX RABIES VACCINE, 50
IN CONTROL PEN NEEDLE, 55
inatal advance, 69
inatal gt, 69
inatal ultra, 69
INCIVEK, 3
INCRELEX, 51
indapamide, 35
indomethacin capsule, -capsule
sustained action, -injection, 58
INFANRIX, 50
INFANRIX PF, 50
INFERGEN, 51
INJECTABLE ANTICOAGULANTS, 63
INJECT-EASE, 55
INPERSOL WITH 1.5% DEXTROSE, 61
INPERSOL WITH 4.25% DEXTROSE,
61
INSULIN, 42
INSULIN LIKE GROWTH FACTORS-1,
51
INSULIN PEN NEEDLE, 55
INSULIN SYR 1/2 ML BULK PACK, -1
ML SYRN 27X1/2, -1 ML SYRN
28GX1/2, -INSUL SYR U100, -INSUL
SYR U100 0.5 ML, -INSUL SYR U100
1 ML, -INSULIN SYR 0.3 ML, INSULIN SYR 0.5 ML, -INSULIN SYR
U-100, -INSULIN SYRN 3/10 ML, SYRINGE 0.3 ML, -SYRINGE 0.5 ML,
-SYRINGE 1 ML, 55
INSULIN SYRINGE 0.3 ML, -INSULIN
SYRINGE 0.5 ML, -INSULIN
SYRINGE 1 ML, -0.3 ML, -0.5 ML, 55
INSUMED, 55
INSUPEN, 55
INTEGRA SYRINGE DISPOSABLE
SYRINGE, -BD INTEGRA SYR 1 ML
29GX1/2, 55
INTELENCE, 3
INTERFERONS, 51
INTERLEUKIN RECPTR ANTAGONIST,
51
INTERLEUKINS, 52
INTRALIPID, 65
INTRON A 10 MILLION UNIT/ML, -18
MILLION UNITS VIAL, -50 MILLION
UNITS VIAL, 51
INTRON A 3 MILLION UNIT/ML PEN, 10 MILLION UNITS VIAL, 51
INTRON A 5 MILLION UNIT/ML PEN, 6 MILLION UNIT/ML VL, -10
MILLION UNIT PEN, 51
introvale, 66
INVANZ, 6
INVEGA ER 1.5 MG TABLET, -ER 3 MG
TABLET, -ER 9 MG TABLET, 18
INVEGA ER 6 MG TABLET, 18
INVEGA SUSTENNA 117 MG PREF SY,
-156 MG PREF SY, -234 MG PREF
SY, 19
INVEGA SUSTENNA 39 MG PREF SYR,
-78 MG PREF SYR, 19
INVIRASE, 3
IONOSOL B WITH DEXTROSE 5%, 61
IONOSOL MB-DEXTROSE 5%, 61
IONOSOL T-DEXTROSE 5%, 61
IOPIDINE, 72
IPOL, 50
ipratropium bromide aerosol spray, 40
ipratropium bromide solution non-oral,
77
ipratropium-albuterol, 77
Page 97 of 117
IRESSA, 14
irinotecan hcl, 14
IRRITABLE BOWEL DRUGS, 46
ISENTRESS, 3
isoditrate, 32
ISOLYTE H WITH DEXTROSE, 61
ISOLYTE M WITH DEXTROSE, 61
ISOLYTE P WITH DEXTROSE, 61
ISOLYTE S, 61
ISOLYTE S WITH DEXTROSE, 61
isonarif, 3
isoniazid injection, -syrup, -tablet, 3
ISOPTO CARBACHOL, 72
ISORDIL, 32
isosorbide dinitrate, 32
isosorbide mononitrate, 32
isradipine, 30
ISUPREL, 34
itraconazole capsule, 5
IXEMPRA, 14
IXIARO, 50
JALYN, 78
jantoven, 63
JANUMET, 43
JANUVIA, 43
jevantique, 68
JE-VAX, 50
jinteli, 68
jolessa, 66
jolivette, 71
junel, 66
junel fe, 66
k effervescent, 64
KALETRA 100-25 MG TABLET, 3
KALETRA SOLUTION, -200-50 MG
TABLET, 3
kalexate, 64
kanamycin sulfate injection, 2
kaon-cl 10, 64
kariva, 66
KAYEXALATE, 64
kcl 20 meq in d5w solution, -kcl 40
meq in d5w solution, 64
KEFLEX 750 MG CAPSULE, 5
kelnor 1-35, 66
KENALOG-10, 41
KENALOG-40, 41
KEPIVANCE, 50
KEPPRA SOLUTION, 25
KEPPRA XR, 25
KERATOLYTIC DRUGS, 36
ketoconazole cream, -shampoo, 8
ketoconazole tablet, 5
ketoprofen capsule, -capsule 24hr
sustained release pellets, 58
ketorolac tromethamine drops, 75
ketorolac tromethamine injection, 58
ketorolac tromethamine tablet, 58
KINERET, 51
kionex suspension oral, 64
klor-con 10, 64
klor-con 20 meq packet, 64
klor-con 8, 64
klor-con m10, 64
klor-con m15, 64
klor-con m20, 64
KOMBIGLYZE XR, 43
KRYSTEXXA, 58
KUVAN, 44
labetalol hcl injection, -tablet, 30
LACRISERT, 75
lactated ringers, 61
lactic acid cream, -lotion, 38
lactulose, 59
LAMICTAL ODT, 25
LAMICTAL ODT (BLUE), 25
LAMICTAL ODT (GREEN), 25
LAMICTAL ODT (ORANGE), 25
lamotrigine, 25
lansoprazole capsule enteric coated, tablet, 48
LANTUS, 42
LANTUS SOLOSTAR, 42
Page 98 of 117
latanoprost, 72
LATUDA, 19
LAXATIVES AND CATHARTICS, 46
leena, 66
leflunomide, 14
lessina, 67
LETAIRIS, 31
letrozole, 14
leucovorin calcium injection, -tablet,
14
LEUKERAN, 14
LEUKINE, 52
LEUKOTRIENE MODIFIERS, 76
leuprolide acetate injection, 71
LEVALBUTEROL CONCENTRATE, 76
LEVAQUIN, 10
LEVATOL, 30
LEVEMIR, 42
levetiracetam, 25
levobunolol hcl, 72
levocarnitine injection, -solution, tablet, 65
levocetirizine dihydrochloride, 76
levofloxacin drops, 74
levofloxacin injection, -solution, tablet, 10
levofloxacin-d5w, 10
levonorgestrel, 67
levora-28, 67
levorphanol tartrate tablet, 21
levothroid, 45
levothyroxine sodium injection, -tablet,
45
levoxyl, 45
LEVSIN INJECTION, 45
LEXAPRO 10 MG TABLET, 28
LEXAPRO 5 MG TABLET, -20 MG
TABLET, 28
LEXAPRO SOLUTION, 28
LEXIVA SUSPENSION ORAL, 3
LEXIVA TABLET, 3
LIALDA, 47
lidocaine hcl cream, -jel, -lotion, ointment, -solution non-oral, 1
lidocaine hcl injection, 1
lidocaine hcl viscous, 1
lidocaine-hydrocortisone cream, lidocaine 3%-hc 0.5% cream, lotion, 38
lidocaine-prilocaine, 1
LIDODERM, 1
LINCOCIN, 6
LINDANE, 37
liothyronine sodium injection, -tablet,
45
LIPITOR, 31
LIPOSYN II, 65
liposyn iii, 65
LISCO, 55
lisinopril tablet, 29
lisinopril-hydrochlorothiazide, 33
LITE TOUCH INSULIN 0.3 ML SYR, INSULIN 0.5 ML SYR, -INSULIN SYR
0.3 ML, -INSULIN SYR 0.5 ML, INSULIN SYR 1 ML, 55
LITE TOUCH INSULIN 1 ML SYR, 55
LITE TOUCH INSULIN PEN NEEDLES,
55
lithium, 18
lithium carbonate capsule, -tablet, tablet sustained action, 18
LOCAL ANESTHETICS, 1
LODOSYN, 26
LOFIBRA 160 MG TABLET, 32
LOOP DIURETICS, 32
loperamide capsule, 45
loryna, 67
losartan potassium, 29
losartan-hydrochlorothiazide, 33
LOTEMAX SUSPENSION DROPS, 73
LOTRONEX, 46
lovastatin, 31
LOVAZA, 32
Page 99 of 117
LOVENOX 300 MG VIAL, -300 MG/3 ML
VIAL, 63
low-ogestrel, 67
loxapine, 19
LUCENTIS, 75
ludent fluoride 0.5 mg tb chew, -1 mg
tab chew, 62
LUMIGAN, 72
LUMIZYME, 44
LUNESTA, 27
LUPRON DEPOT 11.25 MG 3MO KIT, 22.5 MG 3MO KIT, 71
LUPRON DEPOT 3.75 MG KIT, 72
LUPRON DEPOT 45 MG 6MO KIT, 14
LUPRON DEPOT 7.5 MG KIT, 72
LUPRON DEPOT-4 MONTH KIT, 72
LUPRON DEPOT-PED 11.25 MG KIT, 15 MG KIT, 72
LUPRON DEPOT-PED 7.5 MG KIT, 72
lutera, 67
LYRICA 225 MG CAPSULE, -300 MG
CAPSULE, 25
LYRICA 25 MG CAPSULE, -50 MG
CAPSULE, -75 MG CAPSULE, -100
MG CAPSULE, -150 MG CAPSULE, 200 MG CAPSULE, 25
LYSODREN, 14
LYSTEDA, 39
MACRODANTIN 25 MG CAPSULE, 11
MAGELLAN INSULIN SAFETY SYRNG,
55
MAGELLAN INSULIN SYRINGE, 55
magnesium sulfate injection, 61
MAGNESIUM SULFATE-D5W, 61
MAKENA, 71
MALARONE, 10
malathion, 37
MAO INHIBITORS, 24
maprotiline hcl, 26
MARPLAN, 24
MATULANE, 15
matzim la, 30
MAXAIR AUTOHALER, 76
MAXALT 10 MG TABLET, 24
MAXALT 5 MG TABLET, 24
MAXALT MLT 10 MG TABLET, 24
MAXALT MLT 5 MG TABLET, 24
MAXIDEX, 73
mebendazole tablet chewable, 2
meclizine hcl tablet, 20
meclofenamate sodium capsule, 58
MEDICAL (MISCELLANEOUS)
SUPPLIES, 52
medroxyprogesterone acetate
injection, -tablet, 71
mefloquine hcl, 10
MEGACE ES, 15
megestrol acetate suspension oral, tablet, 15
meloxicam suspension oral, -tablet, 58
melphalan hcl, 15
MENACTRA, 50
MENEST, 68
MENOMUNE-A-C-Y-W-135, 50
MENOSTAR, 68
MENVEO A-C-Y-W-135-DIP, 50
meperidine hcl injection, -solution, tablet, 21
meperitab, 21
meprobamate, 20
MEPRON, 6
mercaptopurine tablet, 15
meropenem, 6
MERUVAX II VACCINE W-DILUENT, 50
mesalamine enema, 47
MESNEX INJECTION, 15
MESNEX TABLET, 15
MESTINON SYRUP, 27
metadate er, 23
metaproterenol sulfate syrup, -tablet,
76
metformin hcl, 43
metformin hcl er tablet sustained
release 24hr, 43
Page 100 of 117
metformin hcl er unknown, 43
methadone hcl injection, -solution, tablet, -tablet soluble, 21
methadone intensol, 21
methadose, 21
methamphetamine hcl, 23
methazolamide tablet, 72
methenamine hippurate, 11
methenamine mandelate tablet, 11
METHERGINE INJECTION, 69
methimazole tablet, 41
methocarbamol tablet, 57
methotrexate injection, -tablet, 15
methscopolamine bromide tablet, 45
methyclothiazide, 35
METHYL XANTHINE DRUGS, 77
methyldopa, 31
methyldopa-hydrochlorothiazide, 33
methyldopate hcl, 31
methylergonovine maleate, 69
methylin 10 mg tablet, 23
methylin 20 mg tablet, 23
methylin 5 mg tablet, 23
methylin er 10 mg tablet, 23
methylin er 20 mg tablet, 23
methylphenidate 10 mg tablet, 23
methylphenidate 20 mg tablet, 23
methylphenidate 5 mg tablet, 23
methylphenidate er, 23
methylphenidate hcl solution, 23
METHYLPHENIDATE HCL UNKNOWN,
23
methylphenidate sr, 23
methylprednisolone acetate injection,
41
methylprednisolone sod succ, 41
methylprednisolone tablet, -tablet
dose pack, 41
metipranolol, 72
metoclopramide hcl injection, -solution
oral, -tablet, 46
metolazone, 35
metoprolol succinate, 30
metoprolol tartrate injection, -tablet,
30
metoprolol-hydrochlorothiazide, 33
metro iv, 2
metronidazole capsule, -injection, tablet, 2
metronidazole cream, -gel, -lotion, 35
metronidazole gel with applicator, 69
mexiletine hcl capsule, 29
MIACALCIN INJECTION, 44
MICARDIS, 29
MICARDIS HCT, 33
miconazole 3 suppository vaginal, 11
microgestin, 67
microgestin fe, 67
MICRO-K 8 MEQ EXTENCAPS, 64
MICRONOR, 71
midodrine hcl, 34
migergot, 24
MIGRANAL, 24
mimvey, 68
MINERALOCORTICOID DRUGS, 42
minocycline hcl capsule, -tablet, 10
minoxidil tablet, 35
mirtazapine, 26
MISCELLANEOUS DRUGS, 39
misoprostol, 46
mitomycin injection, 15
mitoxantrone hcl, 15
M-M-R II VACCINE, 50
moexipril hcl, 29
moexipril-hydrochlorothiazide, 33
mometasone furoate cream, ointment, -solution non-oral, 38
MONOJECT 0.5 ML SYRN 28GX1/2, 55
MONOJECT INSULIN SAFETY SYRNG,
55
MONOJECT INSULIN SYR 1 ML, 55
MONOJECT SAFETY SYRINGE, 55
mononessa, 67
MONUROL, 11
Page 101 of 117
morphine sulfate in dextrose, 21
morphine sulfate injection, -solution, suppository rectal, -tablet, 21
morphine sulfate tablet sustained
action, 21
MOTOFEN, 45
MOXEZA, 74
MOZOBIL, 50
mst 600, 59
MULTAQ, 33
multinatal plus tablet, 69
multi-nate dha extra, 69
multi-vitamin w-fluoride-iron, 65
multivitamins w-fluoride-iron, 65
multivitamins with fluoride drops, multivit-fluor 0.25 mg tab chw, mult-vit-fluor 0.5 mg tab chw, multivit-fluor 0.5 mg tab, -multivitfluor 0.5 mg tab chew, 65
multivit-fluor 0.25 mg tab chw, multivit-fluor 0.5 mg tab chw, 65
multivit-fluor 0.5 mg tab chew, 65
mupirocin ointment, 11
MUSCULOSKELETAL MEDICATIONS,
57
MUSTARGEN, 15
MVC-FLUORIDE 0.5 MG TAB CHEW, 65
MYCAMINE, 8
MYCOBUTIN, 3
mycophenolate mofetil, 15
mydral, 75
MYELOID STIMULANTS, 52
MYFORTIC, 15
mynatal, 69
mynatal advance, 69
mynatal plus, 69
mynatal-z, 69
mynate 90 plus, 69
myochrysine, 59
MYOZYME, 44
MYTELASE, 27
nabumetone, 58
nadolol tablet, 30
nadolol-bendroflumethiazide, 33
NAFCILLIN 1 GM/ 50 ML INJ, 9
nafcillin 2 gm/ 100 ml inj, 9
nafcillin sodium, 9
NAFTIN, 8
NAGLAZYME, 44
nalbuphine hcl injection, 17
naloxone hcl injection, 27
naltrexone hcl tablet, 27
NAMENDA, 18
naphazoline hcl drops, 75
naproxen sodium 275 mg tab, -550
mg tab, 58
naproxen suspension oral, -tablet, tablet enteric coated, 58
naratriptan hcl, 24
NASONEX, 40
NATACYN, 75
nateglinide, 43
nature-throid, 45
NAVANE 20 MG CAPSULE, 19
NEBUPENT, 6
necon, 67
nefazodone hcl, 26
NEO-FRADIN, 2
neofrin, 75
neomycin sulfate tablet, 2
neomycin-bacitracin-poly-hc, 73
neomycin-bacitracin-polymyxin, 74
neomycin-poly-hc eye drops, 73
neomycin-polymixin-hc ear susp, -ear
susp, 40
neomycin-polymyxin-dexameth, 73
neomycin-polymyxin-gramicidin, 74
neomycin-polymyxin-hydrocort, 40
neomy-polymyxin b 40 mg/ml amp, 78
neostigmine methylsulfate, 27
NEPHRAMINE, 61
NEULASTA, 52
NEUMEGA, 52
NEUPOGEN, 52
Page 102 of 117
NEVANAC, 75
NEXAVAR, 15
next choice, 67
NIASPAN, 32
nicardipine hcl, 30
NICOTROL, 28
NICOTROL NS, 28
nifediac cc, 30
nifedical xl, 30
nifedipine capsule, 30
nifedipine er tablet sustained action,
30
NILANDRON, 15
nimodipine, 30
nisoldipine, 30
NITRATES, 32
nitro-bid, 32
NITRO-DUR 0.3 MG/HR PATCH, -0.8
MG/HR PATCH, 32
nitrofurantoin macrocrystal capsule, 11
nitrofurantoin mono-macro, 11
nitrofurantoin suspension oral, 11
nitroglycerin injection, 32
nitroglycerin patch, 32
NITROLINGUAL, 32
NITROSTAT, 33
nizatidine, 46
NON-STEROIDAL
ANTIINFLAMMATORY AGENTS, 58
nora-be, 71
NORDIPEN 15, 55
NORDIPEN 5, 55
NORDITROPIN, 48
NORDITROPIN FLEXPRO, 48
NORDITROPIN NORDIFLEX 5 MG/1.5,
-NORDIFLX 15 MG/1.5, 48
NORDITROPIN NORDIFLX 10 MG/1.5,
-30 MG/3, 48
norethindrone, 71
norethindrone acetate tablet, 71
norgestimate-ethinyl estradiol, 67
norgestrel-ethiny estra, 67
NORMOSOL-M AND DEXTROSE, 61
NORMOSOL-R, 61
NORMOSOL-R AND DEXTROSE, 61
NORMOSOL-R PH 7.4, 61
NOROXIN, 10
NORPACE CR 100 MG CAPSULE, 29
nortrel, 67
nortriptyline hcl capsule, -solution, 27
NORVIR CAPSULE, -TABLET, 3
NORVIR SOLUTION, 3
NOVAMINE, 61
novarel, 72
NOVOFINE 32, 55
NOVOFINE AUTOCOVER, 55
NOVOLIN 70-30 100 UNIT/ML VIAL,
42
NOVOLIN N 100 UNITS/ML VIAL, 42
NOVOLIN R, 42
NOVOLOG, 42
NOVOLOG MIX 70-30, 42
NOVOPEN 3, 55
NOVOPEN JR, 56
NOXAFIL, 6
np thyroid, 45
NUEDEXTA, 27
NULOJIX, 15
nutrilyte, 61
nutrilyte ii, 61
NUTRITION,BLOOD
MODIFIERS,ELECTROLYTES, 59
NUTROPIN, 48
NUTROPIN AQ, 48
NUTROPIN AQ NUSPIN 10 PEN CART,
-20 PEN CART, 48
NUTROPIN AQ NUSPIN 5 PEN CART,
48
NUVARING, 67
NUVIGIL, 23
nyamyc, 8
nystatin 150,000,000 units pwd, 6
Page 103 of 117
nystatin 50,000,000 units pwd, 500,000,000 units pwd, -suspension
oral, -500,000 unit oral tab, 6
nystatin cream, -ointment, -100,000
unit/gm powd, 8
nystatin vaginal tablet, 11
nystatin-triamcinolone, 11
nystop, 8
ob + dha, 69
ob 90 + dha, 70
OB/GYN TOPICAL ANTIINFECTIVES,
69
ob-natal one, 70
OBSTETRICAL AND GYNECOLOGICAL
MEDICATIONS, 65
ocella, 67
octreotide acet 100 mcg/ml amp, -acet
100 mcg/ml syr, -acet 100 mcg/ml
vl, -acet 200 mcg/ml vl, -acet 500
mcg/ml amp, -acet 500 mcg/ml vl, 1,000 mcg/ml vial, 15
octreotide acet 50 mcg/ml amp, 15
octreotide acet 50 mcg/ml syr, -acet
50 mcg/ml vial, 15
ofloxacin 0.3% ear drops, 40
ofloxacin 0.3% eye drops, 74
ofloxacin tablet, 10
ogestrel, 67
omeprazole dr 10 mg capsule, -dr 20
mg capsule, 48
OMNITROPE, 48
ONCASPAR, 15
ondansetron hcl 24 mg tablet, 20
ondansetron hcl 4 mg tablet, -8 mg
tablet, 20
ondansetron hcl in dextrose, 20
ondansetron hcl injection, 20
ondansetron hcl solution, 20
ondansetron in sodium chloride, 20
ondansetron odt, 20
ONGLYZA, 43
ONSOLIS, 21
ONTAK, 15
OPANA ER, 21
OPHTHALMIC
ANTIINFECTIVE/CORTICOSTEROIDS
, 73
OPHTHALMIC CORTICOSTEROID
DRUGS, 73
OPHTHALMIC MEDICATIONS, 72
OPHTHALMIC TOPICAL
ANTIBACTERIAL DRUGS, 73
OPHTHALMIC TOPICAL ANTIVIRAL
DRUGS, 74
ORAL ANTICOAGULANTS, VITAMIN K,
63
ORAL ANTIFUNGAL DRUGS, 5
ORAL DERMATOLOGICAL DRUGS, 37
ORAL HYPOGLYCEMICS AND COMBOS,
43
ORAP, 19
ORENCIA 250 MG VIAL, 15
ORFADIN, 39
orphenadrine citrate injection, -tablet
sustained action, 57
orphenadrine compound, 57
orphenadrine compound forte, 57
ORSINI INSUL SYR U100 0.5 ML, 56
ORSINI INSUL SYR U100 1 ML, 56
orsythia, 67
ORTHO EVRA, 67
ORTHOCLONE OKT-3, 15
OSMOPREP, 46
OTHER ANTIARRHYTHMICS, 33
OTHER ANTICONVULSANTS, 25
OTHER ANTIDEPRESSANTS, 25
OTHER ANTIHYPERTENSIVES, 33
OTHER ANTIINFECTIVE DRUGS, 6
OTHER ANTIPARKINSON DRUGS, 26
OTHER ANTIULCER DRUGS, 46
OTHER ANTIVIRAL DRUGS, 7
OTHER CARDIOVASCULAR DRUGS, 34
OTHER CNS/AUTONOMIC DRUGS, 26
OTHER DRUGS FOR ARTHRITIS, 59
Page 104 of 117
OTHER DRUGS FOR ASTHMA, 77
OTHER ENDOCRINE DRUGS, 43
OTHER GENITOURINARY PRODUCTS,
78
OTHER GI DRUGS, 46
OTHER MACROLIDES, 8
OTHER OPHTHALMIC DRUGS, 74
OTHER RESPIRATORY DRUGS, 78
OTHER TOPICAL ANTIFUNGALS, 8
OTHER VASODILATING DRUGS, 34
OXACILLIN, 9
oxacillin 1 gm add-vantage vl, -1 gm
vial, 9
OXACILLIN 10 GM VIAL, 9
oxacillin 2 gm add-vantage vl, -2 gm
vial, 9
oxaliplatin, 15
oxandrolone tablet, 66
oxaprozin, 58
oxcarbazepine, 21
OXISTAT, 8
OXSORALEN-ULTRA, 37
oxybutynin chloride er, 78
oxybutynin chloride syrup, -tablet, 78
oxycodone concentrate, 21
oxycodone hcl, 21
oxycodone hcl-acetaminophen, 21
oxycodone hcl-aspirin, 21
oxycodone hcl-ibuprofen, 22
oxycodone-acetaminophen, 22
oxycodone-aspirin, 22
oxymorphone hcl tablet, 22
oxymorphone hcl tablet sustained
release 12hr, 22
OXYTOCICS, 69
oxytocin injection, 69
pacerone, 29
paclitaxel 100 mg/16.7 ml vial, -30
mg/5 ml vial, 15
paclitaxel 300 mg/50 ml vial, 15
pamidronate 30 mg/10 ml vial, -90
mg/10 ml vial, 44
PAMIDRONATE 60 MG/10 ML VIAL, 44
pamidronate disod 30 mg vial, -disod
90 mg vial, 44
PANCREAZE, 47
PANCRELIPASE 5,000, 47
PANRETIN, 38
pantoprazole sodium, 48
papaverine hcl injection, 34
parcaine, 75
paregoric, 45
PARENTERAL ANTIFUNGALS, 8
paromomycin sulfate, 1
paroxetine hcl, 28
PASER, 4
PATANASE, 40
PATANOL, 75
PCE, 5
PEDIARIX, 50
pedi-dri, 8
PEDVAXHIB, 50
peg 3350-electrolyte, 47
PEG 3350-GRX, 57
peg-3350 and electrolytes, 47
peg-3350 with flavor packs, 47
PEGANONE, 24
PEGASYS 180 MCG/0.5 ML CONV.PK,
51
PEGASYS 180 MCG/ML VIAL, 51
PEGINTRON 50 MCG KIT, 51
PEGINTRON 80 MCG KIT, -120 MCG
KIT, -150 MCG KIT, 51
PEGINTRON REDIPEN, 51
PEN NEEDLES, 56
penicillin g potassium, 9
penicillin g procaine, 9
penicillin g sodium, 9
PENICILLIN GK-ISO-OSM DEXTROSE,
9
penicillin v potassium, 9
PENICILLINS, 8
PENTASA, 47
pentazocine-acetaminophen, 22
Page 105 of 117
pentazocine-naloxone hcl, 23
pentopak, 34
pentostatin, 15
pentoxifylline tablet sustained action,
34
pepcid injection, 46
PERFOROMIST, 76
perindopril erbumine, 29
permethrin cream, 37
perphenazine, 19
perphenazine-amitriptyline, 26
PFIZERPEN, 9
PHARMACEUTICAL NECESSITIES, 57
phenadoz, 20
phenazopyridine plus, 78
phenelzine sulfate tablet, 24
phenylephrine hcl drops, 75
phenylephrine hcl injection, 34
PHENYTEK, 24
phenytoin sodium extended, 24
phenytoin sodium injection, 24
phenytoin suspension oral, 24
phluorivit, 65
phluorivit + fe, 65
PHOSLYRA, 65
phosphasal, 79
PHOSPHOLINE IODIDE, 72
PHOTOFRIN, 15
PHYSIOLYTE, 61
PHYSIOSOL, 61
physostigmine salicylate injection, 27
pilocarpine hcl drops, 72
pilocarpine hcl tablet, 40
PILOPINE HS, 72
pindolol, 30
piperacillin, 9
piperacillin-tazobactam, 9
piroxicam capsule, 58
PLAN B, 67
PLAN B ONE-STEP, 67
PLASMA-LYTE 148, 61
PLASMA-LYTE 148 IN DEXTROSE, 61
PLASMA-LYTE 56, 61
PLASMA-LYTE 56 IN DEXTROSE, 61
PLASMA-LYTE A PH 7.4, 61
PLASMA-LYTE R, 61
PLASMODICIDES, 9
PLAVIX, 59
pnv-dha + docusate, 70
pnv-total, 70
PODOCON-25, 36
podofilox, 36
poly-650, 17
polycin-b, 74
poly-dex, 73
polyethylene glycol 3350, 46
polyethylene glycol 3350 packet, 46
polymyxin b sulfate injection, 6
polymyxin b sul-trimethoprim, 74
POLY-PRED, 73
POLYTRIM, 74
polyvitamin with iron-fluoride, 65
polyvitamins-fluoride, 65
portia, 67
potassium acetate injection, 64
potassium bicarbonate tablet
effervescent, 64
potassium chl-normal saline, 62
potassium chloride capsule sustained
action, -injection, -solution, -tablet
effervescent, -tablet
sust.releaseparticles/crystals, -tablet
sustained action, 64
potassium chloride in d5lr, 64
potassium chloride-nacl, 62
potassium citrate TABLET SUSTAINED
ACTION, 79
potassium citrate-citric acid, 79
potassium ph 3mm/ml vial, 62
POTASSIUM REMOVING RESINS, 64
POTASSIUM SPARING DIURETICS, 34
POTASSIUM SUPPLEMENTS, 64
pr natal 430 ec, 70
PRADAXA, 63
Page 106 of 117
pramipexole dihydrochloride, 26
PRANDIN, 43
prascion, 35
pravastatin sodium, 31
prazosin hcl, 35
pre-attached lta kit, 1
PRECISION, 56
PRED MILD, 73
PRED-G, 73
prednicarbate, 38
prednisolone acetate suspension
drops, 73
prednisolone sodium phosphate drops,
73
prednisolone sodium phosphate
solution, 41
prednisolone solution oral, 41
prednisone intensol, 41
prednisone solution, -tablet, 41
PREFEST, 68
PREMARIN CREAM WITH
APPLICATOR, -TABLET, 68
PREMARIN INJECTION, 68
PREMASOL, 62
PREMPHASE, 68
PREMPRO, 69
prenacare, 70
prenafirst, 70
prenaplus, 70
prenatabs fa, 70
prenatabs obn, 70
prenatabs rx, 70
prenatal 19, 70
prenatal ad, 70
prenatal low iron, 70
prenatal multivitamin w-iron, 70
prenatal plus, 70
PRENATAL VITAMINS, 69
prenatal-u, 70
prenate plus, 70
PREVIDENT 5000, 62
PREVIDENT SOLUTION NON-ORAL, 62
previfem, 67
PREVPAC, 47
PREZISTA 400 MG TABLET, -600 MG
TABLET, 3
PREZISTA 75 MG TABLET, -150 MG
TABLET, 3
PRIALT, 17
PRIFTIN, 4
PRIMAQUINE, 10
PRIMAXIN 250 MG VIAL, 6
PRIMAXIN 500 MG VIAL, 6
PRIMAXIN I.M., 6
primidone tablet, 25
PRISTIQ, 26
PRIVIGEN, 50
PROAIR HFA, 76
probenecid, 58
probenecid-colchicine, 58
procainamide hcl injection, 29
PROCALAMINE, 62
prochlorperazine edisylate, 20
prochlorperazine maleate suppository
rectal, -tablet, 20
PROCRIT 2,000 UNITS/ML VIAL, 3,000 UNITS/ML VIAL, -4,000
UNITS/ML VIAL, -10,000 UNITS/ML
VIAL, 50
PROCRIT 20,000 UNITS/ML VIAL, 40,000 UNITS/ML VIAL, 50
PROCTOFOAM-HC, 47
procto-pak, 47
proctozone-hc, 47
PRODIGY INSULIN SYRINGE, 56
PRODIGY PEN NEEDLE, 56
PROGESTIN DRUGS, 71
PROGLYCEM, 42
PROGRAF INJECTION, 15
PROLASTIN 1,000 MG VIAL, 78
PROLASTIN 500 MG VIAL, 78
PROLASTIN C, 78
PROLEUKIN, 52
PROLIA, 44
Page 107 of 117
PROMACTA 25 MG TABLET, 52
PROMACTA 50 MG TABLET, -75 MG
TABLET, 52
promethazine hcl injection, -syrup, tablet, 76
promethazine hcl suppository rectal,
20
promethazine vc, 75
promethegan, 20
PROMETRIUM, 71
propafenone hcl, 29
propantheline bromide tablet, 46
proparacaine hcl drops, 75
propranolol hcl capsule sustained
action, -injection, -solution, -tablet,
30
propranolol-hydrochlorothiazid, 33
propylthiouracil, 41
PROQUAD, 50
PROSOL, 62
PROSTIGMIN, 27
PROTON PUMP INHIBITORS, 48
PROTONIX IV, 48
PROTOPIC, 38
protriptyline hcl, 27
PROVENTIL HFA, 76
PROVIGIL, 23
PRUDOXIN, 38
PULMOZYME, 78
pyrazinamide, 4
pyridostigmine bromide tablet, 27
quasense, 67
quinapril hcl, 29
quinapril-hydrochlorothiazide, 33
quinidine gluconate, 29
quinidine sulfate tablet, -tablet
sustained action, 29
QUINOLONES, 10
QVAR, 77
RABAVERT, 50
ramipril, 29
RANEXA ER 1,000 MG TABLET, 34
RANEXA ER 500 MG TABLET, 34
ranitidine hcl capsule, -injection, syrup, -150 mg tablet, -300 mg
tablet, 46
RAPAMUNE, 15
RAZADYNE SOLUTION, 18
REBETOL CAPSULE, 7
REBETOL SOLUTION, 7
REBIF 22 MCG/0.5 ML SYRINGE, -44
MCG/0.5 ML SYRINGE, 51
REBIF TITRATION PACK, 51
RECLAST, 44
reclipsen, 67
RECOMBIVAX HB, 50
REGONOL, 27
REGRANEX, 38
RELENZA, 7
RELION NOVOLIN 70-30 VIAL, 42
RELION NOVOLIN N 100 UNITS/ML,
42
RELION PEN 29G NEEDLE, -RELION
PEN 31G NEEDLE, 56
RELISTOR 12 MG/0.6 ML KIT, 47
RELISTOR 12 MG/0.6 ML VIAL, 47
remeven, 38
REMICADE, 15
REMODULIN, 34
renaf fluoride 0.5 mg tab chew, fluoride 1 mg tab chew, 62
RENAGEL, 59
RENAMIN, 62
re-nata 29 ob, 70
RENVELA, 59
RESCRIPTOR, 3
reserpine tablet, 33
RESPIRATORY MEDICATIONS, 75
RESTASIS, 75
RETROVIR INJECTION, 3
REVATIO TABLET, 34
REVLIMID, 15
REYATAZ, 3
RIBAPAK, 7
Page 108 of 117
RIBASPHERE 400 MG TABLET, -600
MG TABLET, 7
ribasphere capsule, -200 mg tablet, 7
RIBATAB 400-400 MG DOSEPACK, 600-600 MG DOSEPACK, 7
RIBAVIRIN 400 MG TABLET, -600 MG
TABLET, 7
ribavirin capsule, -200 mg tablet, 7
RIDAURA, 59
RIFAMATE, 4
rifampin capsule, 4
rifampin injection, 4
RIFATER, 4
RILUTEK, 57
rimantadine hcl, 7
ringers injection, 62
ringers irrigation, 62
RIOMET, 43
RISPERDAL CONSTA 12.5 MG SYR, -25
MG SYR, 19
RISPERDAL CONSTA 37.5 MG SYR, -50
MG SYR, 19
risperidone m-tab, 19
risperidone odt, 19
risperidone solution, 19
risperidone tablet, 19
RITUXAN, 15
rivastigmine, 18
romycin, 74
ropinirole hcl, 26
rosaderm cleanser, 36
ROTARIX, 50
ROTATEQ, 50
roxicet 5-325 tablet, 22
ROXICET SOLUTION, 22
ROXICODONE INTENSOL, 22
ROXICODONE SOLUTION, 22
ROXICODONE TABLET, 22
SABRIL, 25
SAFESNAP INSULIN SYRINGE, 56
SAFETY SYRINGE WITH SHIELD, 56
SAFETYGLIDE INSULIN SYRINGE, 56
SAIZEN 5 MG VIAL, -8.8 MG
CLICK.EASY CARTG, 48
SAIZEN 8.8 MG VIAL, 48
SALICYLATES AND RELATED DRUGS,
59
salicylic acid gel, 36
salicylic acid liquid, 36
salicylic acid shampoo, 36
saline 0.45% soln-excel con, -0.45%
soln, -saline 0.9% soln-excel cont, 0.9% soln, -0.9% soln., -0.9%
solution, -cl 2.5 meq/ml vial, -3% iv
soln, -4 meq/ml vl, -5% iv soln, 62
salsalate tablet, 59
SAL-TROPINE, 46
SAMSCA 15 MG TABLET, 44
SAMSCA 30 MG TABLET, 44
SANCUSO, 20
SANDIMMUNE SOLUTION, 15
SANDOSTATIN, 15
SANDOSTATIN LAR, 15
SANTYL, 38
SAPHRIS, 19
SAVELLA TABLET, 26
SAVELLA TABLET DOSE PACK, 26
SCABICIDES, 37
SCOPACE, 46
SCOPOLAMINE HYDROBROMIDE
INJECTION, 46
seb-prev, 36
se-care conceive, 70
se-care gesture, 70
SECONDARY AMINES, 27
SEDATIVE/HYPNOTIC DRUGS, 27
SELECTIVE SEROTONIN REUPTAKE
INHIBITORS, 27
selegiline hcl capsule, -tablet, 26
selenium sulfide shampoo, -suspension
topical, 36
selfemra, 28
SELZENTRY, 3
SEMPREX-D, 75
Page 109 of 117
se-natal 19, 70
se-natal 90, 70
se-natal one, 70
SENSIPAR 30 MG TABLET, 44
SENSIPAR 60 MG TABLET, -90 MG
TABLET, 44
se-plete dha, 70
SEREVENT DISKUS, 76
SEROMYCIN, 4
SEROQUEL, 19
SEROQUEL XR 150 MG TABLET, -200
MG TABLET, 19
SEROQUEL XR 50 MG TABLET, -300
MG TABLET, -400 MG TABLET, 19
SEROSTIM, 48
sertraline hcl solution, -tablet, 28
setonet, 70
setonet-ec, 70
sf, 62
sf 5000 plus, 62
silver nitrate ointment, -solution, 38
silver sulfadiazine cream, 11
SIMCOR, 32
SIMPONI 50 MG/0.5 ML PEN INJEC, 16
SIMPONI 50 MG/0.5 ML SYRINGE, 16
SIMULECT, 16
simvastatin, 32
SINGLE USE SWAB, 56
SINGULAIR, 76
SMOKING CESSATION PRODUCTS, 28
sodiphluor, 62
sodium acetate injection, 62
sodium bicarbonate injection, 62
sodium citrate & citric acid, 64
SODIUM EDECRIN, 32
sodium fluoride drops, -tablet, -0.5
mg(1.1 mg), 62
sodium lactate injection, 62
sodium polystyrene sulfonate powder,
64
sodium polystyrene sulfonate
suspension oral, 64
sodium sulfacetamide solution, 36
sodium sulf-sulfur cleanser, -sulf-sulfur
wash, -lotion, -suspensions, (not
oral), 36
SOLARAZE, 38
solia, 67
SOLU-CORTEF, 41
SOLU-CORTEF (PF), 41
SOLU-MEDROL, 41
SOLU-MEDROL (PF), 41
SOMATULINE DEPOT, 16
SOMAVERT 10 MG VIAL, -20 MG VIAL,
44
SOMAVERT 15 MG VIAL, 44
SORIATANE 10 MG CAPSULE, -25 MG
CAPSULE, 16
SORIATANE 17.5 MG CAPSULE, -22.5
MG CAPSULE, 36
SORIATANE CK, 16
sorine, 33
sotalol, 33
sotalol af, 33
sotret, 37
SPECIALIZED OB/GYN DRUGS, 71
SPECTRACEF, 5
SPIRIVA, 77
spironolactone tablet, 34
spironolactone-hctz, 34
sprintec, 67
SPRYCEL 20 MG TABLET, -50 MG
TABLET, -70 MG TABLET, 16
SPRYCEL 80 MG TABLET, -100 MG
TABLET, -140 MG TABLET, 16
sps, 64
sronyx, 67
ssd, 11
ssd af, 11
STALEVO 100, 26
STALEVO 125, 26
STALEVO 150, 26
STALEVO 200, 26
STALEVO 50, 26
Page 110 of 117
STALEVO 75, 26
stannous fluoride solution, 62
stavudine, 3
STAVZOR, 28
STELARA 45 MG/0.5 ML SYRINGE, -45
MG/0.5 ML VIAL, 16
STELARA 90 MG/ML SYRINGE, 16
sterile water for irrigation, 62
STIMATE, 44
STRATTERA 10 MG CAPSULE, -40 MG
CAPSULE, -60 MG CAPSULE, -80 MG
CAPSULE, -100 MG CAPSULE, 27
STRATTERA 18 MG CAPSULE, 27
STRATTERA 25 MG CAPSULE, 27
STREPTOMYCIN SULFATE INJECTION,
4
STRIANT, 66
STROMECTOL, 2
sublimaze, 22
SUBOXONE 2 MG-0.5 MG SL FILM, -2
MG-0.5 MG TABLET SL, 22
SUBOXONE 8 MG-2 MG SL FILM, -8
MG-2 MG TABLET SL, 22
SUCCINIMIDES, 28
sucralfate suspension oral, -tablet, 46
sulfacetamide sodium drops, 74
sulfacetamide sodium lotion, suspension topical, 36
sulfacetamide-prednisolone, 73
sulfadiazine tablet, 10
sulfamethoxazole-trimethoprim, 10
sulfamide, 74
sulfasalazine dr, 47
sulfasalazine tablet, 47
sulfazine, 47
sulfazine ec, 47
SULFONAMIDES, 10
sulindac tablet, 58
SUMATRIPTAN, 24
sumatriptan 4 mg/0.5 ml kit, -4
mg/0.5 ml refill, -4 mg/0.5 ml syrng,
-6 mg/0.5 ml inject, -6 mg/0.5 ml
refill, -6 mg/0.5 ml syrng, 24
sumatriptan 4 mg/0.5 ml vial, 24
sumatriptan 6 mg/0.5 ml vial, 24
sumatriptan succinate tablet, 24
SUPARTZ, 59
SUPPRELIN LA, 72
SUPRAX, 5
SURE COMFORT 1 ML SYRINGE, 56
SURE COMFORT ALCOHOL, 56
SURE COMFORT NEEDLE
DISPOSABLE, -0.3 ML SYRINGE, 0.5 ML SYRINGE, -3/10 ML
SYRINGE, 56
SURE-FINE PEN NEEDLES, 56
SURE-JECT INSU SYR U100 0.3 ML, INSU SYR U100 0.5 ML, -INSU SYR
U100 1 ML, -1 ML, 56
SURE-JECT INSUL SYR U100 1 ML, 56
SURE-PREP ALCOHOL PREP PADS, 56
SURMONTIL, 28
SUSTIVA, 3
SUTENT, 16
syeda, 67
SYLATRON, 51
SYLATRON 4-PACK, 51
SYMBICORT, 77
SYMLIN, 42
SYMLINPEN 120, 42
SYMLINPEN 60, 42
SYNAGIS 100 MG/1 ML VIAL, 50
SYNAGIS 50 MG/0.5 ML VIAL, 50
SYNAREL, 72
SYNERA, 1
SYNERCID, 6
SYNVISC, 59
SYNVISC-ONE, 59
SYPRINE, 59
TABLOID, 16
tacrolimus capsule, 16
TAMIFLU 30 MG GELCAP, -45 MG
GELCAP, -SUSPENSION, 7
Page 111 of 117
TAMIFLU 75 MG GELCAP, 7
tamoxifen citrate tablet, 16
tamsulosin hcl, 79
TARCEVA 100 MG TABLET, -150 MG
TABLET, 16
TARCEVA 25 MG TABLET, 16
TARGRETIN CAPSULE, 16
TARGRETIN GEL, 16
taron ec calcium, 70
taron-bc, 70
taron-crystals, 79
taron-duo ec, 70
taron-ec cal, 70
taron-prex prenatal, 70
TASIGNA, 16
TAXOTERE 20 MG/0.5 ML VIAL, -80
MG/2 ML VIAL, 16
taztia xt, 31
TEFLARO, 5
TEGRETOL XR 100 MG TABLET, 21
TEKAMLO, 33
TEKTURNA, 33
TEKTURNA HCT, 33
terazosin hcl, 35
terbinafine hcl tablet, 6
terbutaline sulfate injection, -tablet, 76
terconazole, 11
TERTIARY AMINES, 28
TERUMO INSULIN SYRINGE, 56
TERUMO SURGUARD, 56
TESTIM, 66
TESTOPEL, 66
testosterone cyp 100 mg/ml, 66
testosterone cyp 200 mg/ml, 66
testosterone enanthate injection, 66
TETANUS DIPHTHERIA TOXOIDS, 50
tetanus toxoid adsorbed, 50
TETANUS-DIPHTERIA-DECAVAC, 50
tetracycline hcl capsule, 10
TETRACYCLINES, 10
TEV-TROPIN, 48
THALOMID 150 MG CAPSULE, -200
MG CAPSULE, 39
THALOMID 50 MG CAPSULE, -100 MG
CAPSULE, 39
theochron, 77
theophylline anhydrous tablet
sustained release 12hr, 77
theophylline tablet sustained action,
77
THERACYS, 16
THERAPEUTIC VITAMINS AND
MINERALS, 64
thermazene, 11
THIAZIDE AND RELATED DRUGS, 35
THINPRO INSULIN SYRINGE, 56
thioridazine hcl, 19
THIOTEPA INJECTION, 16
thiothixene, 19
THROMBOPOIETIC AGENTS, 52
THYMOGLOBULIN, 50
THYROGEN, 39
THYROID SUPPLEMENTS, 45
THYROLAR-1, 45
THYROLAR-1/2, 45
THYROLAR-1/4, 45
THYROLAR-2, 45
THYROLAR-3, 45
ticlopidine hcl, 59
TIKOSYN, 33
tilia fe, 67
TIMENTIN, 9
timolol maleate drops, -gel-forming
solution, 72
timolol maleate tablet, 30
TIMOPTIC 0.5% EYE DROPS, 72
tis-u-sol, 62
tizanidine hcl tablet, 57
TOBI, 2
TOBRADEX OINTMENT, 73
tobramycin sulfate drops, 74
tobramycin sulfate in ns, 2
tobramycin sulfate injection, 2
Page 112 of 117
tobramycin-dexamethasone, 73
tobrasol, 74
TOBREX OINTMENT, 74
tolazamide, 43
tolbutamide, 43
tolmetin sodium, 58
TOPCARE CLICKFINE, 56
TOPCARE ULTRA COMFORT, 56
TOPICAL ANESTHETICS, 1
TOPICAL ANTIBACTERIAL DRUGS, 11
TOPICAL ANTIFUNGALCORTICOSTEROID COMB., 11
TOPICAL ANTI-INFLAMMATORY
DRUGS, 37
TOPICAL CORTICOSTEROID DRUGS,
37
TOPICAL DERMATOLOGICAL DRUGS,
38
topiragen, 25
topiramate capsule sprinkle, -tablet, 25
topisulf, 36
topotecan hcl, 16
TORISEL, 16
torsemide, 32
TOVIAZ, 78
TPN ELECTROLYTES, 62
TPN ELECTROLYTES II, 62
TRACLEER, 31
TRADJENTA, 41
tramadol hcl tablet, 17
tramadol hcl-acetaminophen, 17
trandolapril, 29
trandolapril-verapamil, 34
TRANSDERM-SCOP, 20
tranylcypromine sulfate, 24
TRAVASOL, 62
TRAVATAN Z, 72
trazodone hcl tablet, 26
TRECATOR, 4
TRELSTAR 11.25 MG SYRINGE, 16
TRELSTAR 22.5 MG SYRINGE, 16
TRELSTAR 22.5 MG VIAL, 16
TRELSTAR 3.75 MG SYRINGE, 16
TRELSTAR DEPOT, 16
TRELSTAR LA, 16
tretinoin 0.025% cream, -0.05%
cream, -0.1% cream, -gel, 36
tretinoin capsule, 16
trezix, 22
tri rx, 70
triadvance, 70
triamcinolone acetonide cream, -lotion,
-ointment, 38
triamcinolone acetonide injection, 41
triamcinolone acetonide paste, 40
triamterene-hctz, 34
triamterene-hydrochlorothiazid, 34
TRIBENZOR, 34
tricitrates, 79
TRICOR, 32
triderm, 38
trifluoperazine hcl, 19
trifluridine drops, 74
trihexyphenidyl hcl, 18
TRIHIBIT, 50
tri-legest fe, 67
TRILEPTAL SUSPENSION, 21
TRILIPIX, 32
trilyte with flavor packets, 47
trimethobenzamide hcl capsule, injection, 20
trimethoprim tablet, 11
trinessa, 67
TRIOSTAT, 45
TRIPEDIA, 50
triphluorivit, 65
tri-previfem, 67
TRISENOX, 16
tri-sprintec, 67
triveen-duo dha, 70
triveen-ten, 70
triveen-u, 70
tri-vit with fluoride-iron, 65
tri-vitamin with fluoride, 65
Page 113 of 117
tri-vitamin with iron-fluoride, 65
trivora-28, 67
TRIZIVIR, 3
TROPHAMINE, 62
tropicacyl, 75
tropicamide drops, 75
trospium chloride, 78
TRUVADA, 3
TWINJECT, 77
TWINRIX, 50
TWYNSTA, 34
TYGACIL, 6
TYKERB, 16
TYPHIM VI, 50
TYSABRI, 16
TYZEKA, 7
TYZINE, 40
u40, 39
U-CORT, 38
u-kera e urea emollient, 39
ULESFIA, 37
ULORIC 40 MG TABLET, 58
ULORIC 80 MG TABLET, 58
ULTICARE NEEDLE DISPOSABLE, INSUL SYR U100 0.3 ML, -INSUL
SYR U100 0.5 ML, -INSULIN SYR
U100 1 ML, 56
ULTIGUARD SYRINGE EMPTY
DISPOSABLE, 56
ULTILET ALCOHOL SWAB, 56
ULTILET INSULIN SYRINGE 1 ML, 56
ultimatecare one, 70
ULTRA COMFORT NEEDLE
DISPOSABLE, -0.3 ML 29GX1/2, -0.3
ML 30GX5/16, -0.3 ML 31GX5/16, 0.3 ML SYRINGE, -0.5 ML 28GX1/2,
-0.5 ML 29GX1/2, -0.5 ML
30GX5/16, -0.5 ML 31GX5/16, -0.5
ML SYR, -0.5 ML SYRINGE, -1 ML
28GX1/2, -1 ML 29GX1/2, -1 ML
31GX5/16, -3/10 ML SYR, 56
ULTRACOMFORT 30GX0.5 ML SYR, 30GX1 ML SYRINGE, -31GX0.5 ML
SYR, -31GX1 ML SYRINGE, -NEEDLE
DISPOSABLE, -SYRINGE EMPTY
DISPOSABLE, 56
UNASYN 1.5 GM ADD-VANTAGE VL, 1.5 GM PIGGYBACK BOTTLE, -3 GM
ADD-VANTAGE VIAL, -3 GM
PIGGYBACK BOTTLE, 9
UNIFINE PENTIPS, 57
unithroid, 45
urea 40, 39
urea 40% cream, -50% cream, -40%
gel, -50% nail gel, -35% lotion, 40% lotion, -50% nail stick, 39
urea 40% nail film susp, 39
uretron d-s, 11
urin d.s., 79
URINARY ANTIINFECTIVES, 11
urogesic-blue, 11
UROLOGICAL MEDICATIONS, 78
ursodiol capsule, -tablet, 47
UTIRA-C, 11
UVADEX, 16
VAGIFEM, 68
VAGINAL ANTIFUNGALS, 11
valacyclovir, 7
VALCYTE, 7
valproate sodium injection, 28
VALPROIC ACID AND DERIVATIVES,
28
valproic acid capsule, -syrup, 28
VALTURNA, 34
VANCOCIN HCL, 6
VANCOMYCIN, 6
vancomycin 1 gm vial, -10 gm vial, 6
vancomycin 500 mg a/v vial, -500 mg
vial, -750 mg vial, -1 gm add-van
vial, -5 gm vial, 6
VANCOMYCIN HCL 1G/200 ML BAG, 6
vandazole, 69
VANDETANIB 100 MG TABLET, 16
Page 114 of 117
VANDETANIB 300 MG TABLET, 17
VANISHPOINT U-100 29X1/2 SYR, 57
VANTAS, 17
VAQTA, 50
VARIVAX VACCINE, 50
VASODILATOR ANTIHYPERTENSIVES,
35
VECTIBIX 100 MG/5 ML VIAL, 17
VECTIBIX 400 MG/20 ML VIAL, 17
VECTICAL, 36
VELCADE, 17
veletri, 34
velivet, 67
vemavite-prx 2, 70
venlafaxine hcl, 26
venlafaxine hcl er 150 mg cap, 26
venlafaxine hcl er 37.5 mg cap, 26
venlafaxine hcl er 75 mg cap, 26
VENTAVIS 10 MCG/1 ML SOLUTION,
34
VENTAVIS 20 MCG/1 ML SOLUTION,
34
VENTOLIN HFA, 76
VERAMYST, 40
verapamil er, 31
verapamil er pm, 31
verapamil hcl capsule 24hr sustained
release pellets, -injection, -tablet, tablet sustained action, 31
VEREGEN, 39
VERSALON SPONGE, 57
VESICARE, 78
VEXOL, 73
VFEND, 6
VFEND IV, 8
VIBATIV, 7
VIBRAMYCIN SUSPENSION, -SYRUP,
10
VICTOZA 2-PAK, 42
VICTOZA 3-PAK, 42
VICTRELIS, 3
VIDAZA, 17
VIDEX, 3
VIGAMOX, 74
VIIBRYD 10 MG TABLET, 28
VIIBRYD 20 MG TABLET, 28
VIIBRYD 40 MG TABLET, 28
VIMPAT, 25
vinacal, 70
vinate az, 71
vinate az extra, 71
vinate c, 71
vinate calcium, 71
vinate care, 71
vinate gt, 71
vinate ic, 71
vinate ii, 71
vinate one, 71
vinate pn care, 71
vinate ultra, 71
vinate-m, 71
vinblastine 1 mg/ml vial, 17
vinblastine sulf 10 mg vial, 17
vincristine 1 mg/ml vial, 17
vincristine 2 mg/2 ml vial, 17
vinorelbine 10 mg/ml vial, 17
vinorelbine 50 mg/5 ml vial, 17
VIRACEPT POWDER, 3
VIRACEPT TABLET, 3
VIRAMUNE, 3
VIRAMUNE XR, 3
VIRAZOLE, 7
VIREAD, 3
VISICOL, 46
VISTIDE, 7
vitafol-ob, 71
vitafol-pn, 71
VITAMINS AND MINERALS AND
RELATED PRODUCTS, 65
vitaphil, 71
vitaphil + dha, 71
vitazol, 36
VIVAGLOBIN, 50
vol-plus, 71
Page 115 of 117
VOLTAREN GEL, 37
voriconazole, 6
VOTRIENT, 17
VPRIV, 44
VUMON, 17
VYTORIN, 32
warfarin sodium tablet, 63
WEBCOL, 57
WELCHOL, 32
westhroid, 45
XALATAN, 72
XENAZINE 12.5 MG TABLET, 27
XENAZINE 25 MG TABLET, 27
XEOMIN 100 UNITS VIAL, 57
XEOMIN 50 UNITS VIAL, 57
XGEVA, 44
XIBROM, 75
XIFAXAN 200 MG TABLET, 7
XIFAXAN 550 MG TABLET, 7
XOLAIR, 77
XOPENEX 0.31 MG/3 ML SOLUTION, 0.63 MG/3 ML SOLUTION, 76
XOPENEX 1.25 MG/3 ML SOLUTION,
76
XOPENEX CONCENTRATE, 76
XOPENEX HFA, 76
x-viate cream, -gel, 39
XYREM, 27
XYZAL, 76
YF-VAX, 51
YODOXIN, 1
zaclir, 36
zafirlukast, 77
zaleplon, 27
ZANOSAR, 17
zarah, 67
zatean-ch, 71
ZAVESCA, 44
ZAZOLE SUPPOSITORY VAGINAL, 11
ZELAPAR, 26
ZEMAIRA, 78
zema-pak 10 day 1.5 mg tablet, -13
day 1.5 mg tablet, 41
ZEMPLAR, 65
zenchent, 67
ZENPEP, 47
zeosa, 67
ZETIA, 32
ZEVALIN, 17
ZIAGEN, 3
zidovudine, 3
ZINOTIC, 40
ZINOTIC ES, 40
ZIRGAN, 75
ZITHRANOL-RR, 36
ZOLADEX, 17
ZOLINZA, 17
zolpidem tartrate tablet, 27
ZOMETA, 44
ZONALON, 39
zonisamide, 25
ZORBTIVE, 48
ZORTRESS 0.25 MG TABLET, 17
ZORTRESS 0.5 MG TABLET, -0.75 MG
TABLET, 17
ZOSTAVAX, 51
ZOSYN 2.25 GRAM VIAL, -2.25 GM
GALAXY BAG, -2.25 GM PRE-MIX
BAG, -3.375 GM GALAXY BAG, 3.375 GM PRE MIX-BAG, -4.5 GM
GALAXY BAG, -4.5 GM PRE-MIX
BAG, -4.5 GRAM VIAL, -40.5 GRAM
BULK VIAL, 9
zovia 1-35e, 67
zovia 1-50e, 68
ZOVIRAX CREAM, -OINTMENT, 8
ZYFLO CR, 77
ZYLET, 73
ZYMAR, 74
ZYMAXID, 74
ZYPREXA 15 MG TABLET, -20 MG
TABLET, 19
Page 116 of 117
ZYPREXA 2.5 MG TABLET, -5 MG
TABLET, -7.5 MG TABLET, -10 MG
TABLET, 19
ZYPREXA INJECTION, 19
ZYPREXA RELPREVV, 19
ZYPREXA ZYDIS 15 MG TABLET, -20
MG TABLET, 19
ZYPREXA ZYDIS 5 MG TABLET, -10 MG
TABLET, 19
ZYTIGA, 17
ZYVOX, 7
Page 117 of 117

Similar documents