Rx Formulary - Millenium Medical Solutions Corp

Transcription

2015
FORMULARY
To Search this document, simultaneously
press “Control” + “F” (PC) or “Command” + “ F” (Mac),
then type the name of the drug and press “Enter.”
PC
PRESS “CONTROL” + “F”
ctrl
+
F
TYPE DRUG NAME
→
drug name
PRESS “ENTER”
→
enter
MAC
PRESS “COMMAND” + “F”
command
HRINY_MM06.UsDFormulary_110414
+
F
TYPE DRUG NAME
→
drug name
PRESS “RETURN”
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enter
return
The information included in this document applies to all Health Republic plans.
All Health Republic plans are available both on and off the New York State of Health Marketplace.
About this Document
The Health Republic Insurance of New York Formulary (or preferred drug list) is a
comprehensive list of prescription drugs covered through your prescription drug benefit.
The list was created by Health Republic in collaboration with our Pharmacy Benefits
Management partner and a team of independent physicians and pharmacists (the
Pharmacy and Therapeutics Committee) to safely, effectively, and affordably treat a
wide range of medical conditions.
Once you’ve met your health plan’s deductible, the drugs on this list are available to
you from participating pharmacies at co-pays reduced significantly from retail prices.
However, not all plans require you to meet your deductible before co-pay prices go into
effect, so be sure to check your plan’s Certificate of Coverage. Participating pharmacies
include major chains such as Walgreen’s, Rite Aid, CVS, and Walmart, as well as many
locally-owned pharmacies.
To locate a pharmacy, check deductible status, review your claim history, search the
formulary, and view a drug cost calculator, please log in to your Health Republic
Member Center and click on the “Pharmacy” option on the right side of the screen.
HOW TO USE THIS DOCUMENT
When viewed online, this document represents the most current and up-to-date
version of the preferred drug list. To search for a specific drug in this document,
simultaneously press “Control” + “F” (PC) or “Command” + “F” (Mac), then type
the name of the drug and press “Enter.”
There is also an alphabetical index of drug names beginning on Page 244.
If you have any questions about this list please contact Health Republic at
888-990-5702.
Frequently Asked Questions
What is the drug formulary tier system and how does it benefit me?
In order to control cost for our members, we’ve carefully evaluated our preferred drug
list for safety, efficacy, and retail price to develop a five-tier formulary system to reflect
levels of co-payment. This helps us identify drugs that are quite expensive but provide
no additional benefit over other less expensive drugs. Therefore, we’re able to distribute
costs accordingly and maximize value.
HEALTH REPUBLIC INSURANCE OF NEW YORK | 30 Broad St., New York, NY 10004 | 888-990-5702 | HealthRepublicNY.org
The five-tier system structure is:
Co-pay level (exact dollar
amount depends on plan)
Tier
Description
0
$0, regardless of plan
Preferred Preventive Drugs (e.g. smoking cessation
aids and birth control)
1
$
Preferred Generic Drugs
2
$$
Preferred Brand Drugs
3
$$$
Non-Preferred Brand Drugs and Generic Drugs
4
$$$$
Specialty Drugs (e.g. drugs used to treat complex
conditions such as cancer and rheumatoid arthritis)
Why are generic drugs preferred over brand name drugs?
Generic drugs have the same active ingredients, strength, dosage, intended use, and
delivery methods as brand name counterparts except they often cost significantly less.
Asking your provider to prescribe generic over brand name drugs, when medically
appropriate, can help reduce your out-of-pocket costs. (For more information, please
see this fact sheet prepared by the FDA.)
The reason generics cost significantly less than brand name has to do with the patent
rights governing the pharmaceutical industry. When a new drug is developed and
approved by the FDA, the company that designed it is awarded exclusive patent and
branding rights for 20 years. During this time, the company benefits from exclusive
selling rights to that brand drug, allowing them to recoup the tremendous costs of
research and development. When the patent rights expire, other companies are allowed
to manufacture and sell generic versions of the drug under a nonproprietary name
agreed upon by a national council. Since these companies invest only in the manufacturing costs of the drug and are operating in a competitive open market, the cost of
generics is inevitably cheaper than their brand name counterparts.
For example, the brand name drug, Lipitor, a popular medication for lowering LDL
cholesterol levels, became available in generic form in December 2011 and is
known as Atorvastatin. The retail price of Lipitor is relatively expensive compared to
Atorvastatin, a tier 1 generic, which is available to Health Republic members at their
lowest co-pay level.
Are the drugs on this list subject to any restrictions?
Yes. For select drugs on this list, restrictions may apply. These restrictions include
Prior Authorization, Step Therapy, Age Limits, and Quantity Limits (including Max Daily
Dose, Max Package Limit, and Max Fill Limit). Please see the explanations below.
Prior Authorization: For drugs requiring prior authorization, the prescribing physician
must submit a prior authorization form to our Pharmacy Benefits Department demonstrating medical necessity of the drug. In these requests, it is important that the prescribing physician provide thorough documentation, such as other therapies or treatments that have been tried, for how long, and what those results have been. This will
assist the physician or pharmacist who is reviewing the request to understand your
history and the clinical rationale for this request. This is often necessary in the case of
drugs that have safety hazards, a high potential for abuse, or are extremely expensive.
This approval process helps control costs for all our members.
Once your physician has sent the necessary information, a prior authorization decision
should be made within 72 hours (weekends and holidays excluded). If the authorization
is approved, your pharmacy will charge you the standard co-pay according to the drug’s
tier level and your health plan. If it is not approved, you can still purchase the drug, but
you will be responsible for the full cost.
Step Therapy: Step therapy requires that an alternative drug (or drugs) is prescribed
before Health Republic will cover the drug in question. Drugs requiring step therapy
are often popularly prescribed, even when a more cost-effective drug has been recommended by nationally recognized treatment guidelines as the first line of therapy. Step
therapy is a necessary measure to prevent unnecessary costs from being passed on to
members.
Age Limits: These drugs require that certain age restrictions are met before Health
Republic will cover the drug. These limits are consistent with FDA and manufacturer
usage recommendations.
Quantity Limit / Max Daily Dose / Max Package Limit / Max Fill Limit: Some drugs have
quantity limits (including max daily dose, max package limit, and max fill limit), meaning
Health Republic will not cover more than a limited amount of the drug. These limits are
consistent with FDA and manufacturer usage recommendations. They usually apply to
drugs that have been found ineffective or dangerous at higher than normal doses. For
example, strong opioid painkillers are frequently subject to quantity limits because of
their habit forming nature and safety risks.
Can I request an exemption to the above restrictions?
Yes. To request an exemption to any of these restrictions, your physician can submit a
prior authorization form with the appropriate clinical reasoning. Once our Pharmacy
Benefits Department has the necessary information, a decision should be made within
72 hours (weekends and holidays excluded).
Please follow these guidelines for efficient processing of prior authorization requests:
1. Complete the prior authorization form. Be sure to include all pertinent clinical
notes/documentation.
2. Fax to US Script at 866-399-0929.
3. If approved, US Script notifies the prescriber by fax.
4. If the clinical information provided does not explain the reason for the
requested medication, US Script responds to the prescriber by fax, offering
formulary alternatives.
5. For urgent or after-hours requests, a pharmacy can provide up to a 72-hour supply of most medications by calling the US Script Pharmacy Help Desk
at 800-460-8988.
Can this list change?
Yes. As new products and information become available, drugs may be added or
removed from this list. This usually occurs when generic alternatives become available
to expensive brand name drugs, or the safety of a drug is called into question by the
FDA. In the event that a drug is removed from our Preferred Drug List, we will notify our
members. We will never remove a drug without providing an equally effective alternative.
What if my drug is not on this list?
If a drug you’ve been prescribed is not on this list, you can contact our Pharmacy
Benefits Department at 888-990-5702 to request help in selecting a clinically equivalent
alternative. You should also notify your physician to see what other alternatives on the
formulary may be right for you.
If you wish to seek an exemption due to medical necessity, please have your doctor
submit a prior authorization form with the appropriate clinical documentation. We will
usually approve requests for medications that are medically necessary and for which we
do not provide an alternative. Unless otherwise noted, we will not cover the following
drug types: over-the-counter drugs, oral vitamins and minerals, drugs and other agents
used for cosmetic purposes or for hair growth.
If you are a new or prospective member of Health Republic seeking to continue use
of a drug that does not appear on this list, please contact our Pharmacy Benefits
Department to discuss options for continuity of care.
Finally, you can always pay full price for a drug you’ve been prescribed that is not on
this list. This formulary provides you with a list of drugs preferred by Health Republic
that are covered under your pharmacy benefit; however, you are not required to
purchase the drugs on this formulary.
LEGEND
TIER
DESCRIPTION
0
Preventative
1
Preferred Generics
2
Preferred Brands
3
Non-Preferred Brands
4
Specialty
TYPE
DESCRIPTION
QL
Quantity Limit
There is a limit on the amount of drug covered per prescription, or
within a specific time frame.
PA
Prior Authorization
Prior Authorization required before prescription can be filled.
ST
Step Therapy
Requires trial and failure of one or more preferred products prior to
coverage.
GL
Gender Limit
Drug is limited to specific gender.
AL
Age Limit
Drug is limited to specific age.
MDD
Max Daily Dose
A limit on the number of times the drug can be taken per day
MPL
Max Package Limit
A limit on the amount of drug covered per prescription.
MFL
Max Fill Limit
There is a limit on the number of times this drug can be refilled.
Custom
This drug has unique restrictions
C
PAGE 2
LAST UPDATED 11/2014
LIST OF COVERED PRESCRIPTION MEDICATIONS
PRODUCT DESCRIPTION
BRAND/GEN
TIER
LIMITS & RESTRICTIONS
*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*
*Amphetamines**
amphetamine-dextroamphet er cap er 24h 10
mg
generic
1
QL
30 / 30 days
mg
generic
1
QL
30 / 30 days
mg
generic
1
QL
30 / 30 days
mg
generic
1
QL
30 / 30 days
mg
generic
1
QL
30 / 30 days
mg
generic
1
QL
30 / 30 days
amphetamine-dextroamphetamine tab 10 mg
generic
1
QL
90 / 30 days
amphetamine-dextroamphetamine tab 12.5 mg
generic
1
QL
90 / 30 days
generic
1
QL
90 / 30 days
generic
1
QL
90 / 30 days
generic
1
QL
90 / 30 days
generic
1
QL
90 / 30 days
amphetamine-dextroamphetamine tab 7.5 mg
generic
1
QL
90 / 30 days
dextroamphetamine sulfate er cap er 24h 10
mg
generic
1
QL
30 / 30 days
dextroamphetamine sulfate er cap er 24h 15
mg
generic
1
QL
30 / 30 days
dextroamphetamine sulfate er cap er 24h 5 mg
generic
1
QL
30 / 30 days
dextroamphetamine sulfate tab 10 mg
generic
1
QL
90 / 30 days
dextroamphetamine sulfate tab 5 mg
generic
1
QL
90 / 30 days
methamphetamine hcl tab 5 mg
generic
3
QL
120 / 30 days
VYVANSE CAP 20 MG
lisdexamfetamine dimesylate
BRAND
2
QL
30 / 30 days
VYVANSE CAP 30 MG
BRAND
2
QL
30 / 30 days
PAGE 3
PRODUCT DESCRIPTION
BRAND/GEN
TIER
VYVANSE CAP 40 MG
BRAND
2
QL
30 / 30 days
VYVANSE CAP 50 MG
BRAND
2
QL
30 / 30 days
VYVANSE CAP 60 MG
BRAND
2
QL
30 / 30 days
VYVANSE CAP 70 MG
BRAND
2
QL
30 / 30 days
zenzedi tab 10 mg
generic
1
zenzedi tab 5 mg
generic
1
phentermine hcl cap 15 mg
generic
1
PA
phentermine hcl cap 30 mg
generic
1
PA
phentermine hcl cap 37.5 mg
generic
1
PA
phentermine hcl tab 37.5 mg
generic
1
PA
QSYMIA CAP ER 24H 11.25-69 MG
phentermine hcl-topiramate
BRAND
2
PA
QSYMIA CAP ER 24H 15-92 MG
BRAND
2
PA
BRAND
2
PA
BRAND
2
PA
BRAND
3
PA
*Anorexiants Non-Amphetamine**
*Anti-Obesity Agents**
XENICAL CAP 120 MG
orlistat
*Attention-Deficit/Hyperactivity Disorder (ADHD) Agents**
clonidine hcl er tab er 12h 0.1 mg
generic
1
QL
30 / 30 days
INTUNIV TAB ER 24H 1 MG
guanfacine hcl (adhd)
BRAND
2
QL
30 / 30 days
BRAND
2
QL
30 / 30 days
BRAND
2
QL
30 / 30 days
BRAND
2
QL
30 / 30 days
PAGE 4
PRODUCT DESCRIPTION
BRAND/GEN
TIER
STRATTERA CAP 10 MG
atomoxetine hcl
BRAND
3
QL
30 / 30 days
STRATTERA CAP 100 MG
atomoxetine hcl
BRAND
3
QL
30 / 30 days
STRATTERA CAP 18 MG
atomoxetine hcl
BRAND
3
QL
30 / 30 days
STRATTERA CAP 25 MG
atomoxetine hcl
BRAND
3
QL
30 / 30 days
STRATTERA CAP 40 MG
atomoxetine hcl
BRAND
3
QL
30 / 30 days
STRATTERA CAP 60 MG
atomoxetine hcl
BRAND
3
QL
30 / 30 days
STRATTERA CAP 80 MG
atomoxetine hcl
BRAND
3
QL
30 / 30 days
dexmethylphenidate hcl er cap er 24h 15 mg
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
dexmethylphenidate hcl tab 10 mg
generic
1
QL
60 / 30 days
dexmethylphenidate hcl tab 2.5 mg
generic
1
QL
60 / 30 days
dexmethylphenidate hcl tab 5 mg
generic
1
QL
60 / 30 days
metadate er tab er 20 mg
generic
1
QL
90 / 30 days
METHYLIN CHEW TAB 10 MG
methylphenidate hcl
BRAND
2
QL
120 / 30 days
METHYLIN CHEW TAB 2.5 MG
methylphenidate hcl
BRAND
2
QL
120 / 30 days
METHYLIN CHEW TAB 5 MG
methylphenidate hcl
BRAND
2
QL
120 / 30 days
methylin er tab er 10 mg
generic
1
QL
90 / 30 days
methylin er tab er 20 mg
generic
1
QL
90 / 30 days
methylin tab 10 mg
generic
1
QL
120 / 30 days
methylin tab 20 mg
generic
1
QL
120 / 30 days
methylin tab 5 mg
generic
1
QL
120 / 30 days
*Stimulants - Misc.**
PAGE 5
PRODUCT DESCRIPTION
BRAND/GEN
TIER
methylphenidate hcl er (cd) cap er 10 mg
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
methylphenidate hcl er (la) cap er 24h 20 mg
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
methylphenidate hcl er tab er 10 mg
generic
1
QL
90 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
90 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
methylphenidate hcl tab 10 mg
generic
1
QL
120 / 30 days
generic
1
QL
120 / 30 days
generic
1
QL
120 / 30 days
QL
modafinil tab 100 mg
generic
60 / 30 days
1
PA
QL
modafinil tab 200 mg
generic
60 / 30 days
1
PA
QL
NUVIGIL TAB 150 MG
armodafinil
BRAND
NUVIGIL TAB 250 MG
armodafinil
BRAND
NUVIGIL TAB 50 MG
armodafinil
BRAND
PAGE 6
60 / 30 days
3
PA
QL
60 / 30 days
3
PA
QL
60 / 30 days
3
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*AMINOGLYCOSIDES*
*Aminoglycosides**
amikacin sulfate solution 1 gm/4ml
generic
1
PA
amikacin sulfate solution 50 mg/ml
generic
1
PA
amikacin sulfate solution 500 mg/2ml
generic
1
PA
BETHKIS NEBU SOLN 300 MG/4ML
tobramycin
BRAND
3
PA
gentamicin in saline solution 0.6-0.9 mg/ml-%
generic
1
PA
generic
1
PA
GENTAMICIN IN SALINE SOLUTION 0.9-0.9
MG/ML-%
gentamicin in saline
BRAND
2
PA
gentamicin in saline solution 1-0.9 mg/ml-%
generic
1
PA
generic
1
PA
GENTAMICIN IN SALINE SOLUTION 1.4-0.9
MG/ML-%
gentamicin in saline
BRAND
2
PA
generic
1
PA
gentamicin in saline solution 2-0.9 mg/ml-%
generic
1
PA
gentamicin sulfate solution 10 mg/ml
generic
1
PA
gentamicin sulfate solution 40 mg/ml
generic
1
PA
kanamycin sulfate solution 333 mg/ml
generic
1
PA
NEO-FRADIN SOLUTION 25 MG/ML
neomycin sulfate
BRAND
2
PA
neomycin sulfate tab 500 mg
generic
1
paromomycin sulfate cap 250 mg
generic
3
TOBI PODHALER CAP 28 MG
tobramycin
BRAND
2
PA
tobramycin nebu soln 300 mg/5ml
generic
1
PA
TOBRAMYCIN SULFATE IN SALINE
SOLUTION 0.8-0.9 MG/ML-%
tobramycin sulfate in saline
BRAND
2
PA
TOBRAMYCIN SULFATE IN SALINE
SOLUTION 1.2-0.9 MG/ML-%
BRAND
2
PA
PAGE 7
PRODUCT DESCRIPTION
BRAND/GEN
TIER
tobramycin sulfate in saline
tobramycin sulfate recon soln 1.2 gm
generic
1
PA
tobramycin sulfate solution 1.2 gm/30ml
generic
1
PA
tobramycin sulfate solution 10 mg/ml
generic
1
PA
tobramycin sulfate solution 2 gm/50ml
generic
1
PA
tobramycin sulfate solution 80 mg/2ml
generic
1
PA
HUMIRA KIT 20 MG/0.4ML
adalimumab
BRAND
4
PA
HUMIRA KIT 40 MG/0.8ML
adalimumab
BRAND
4
PA
HUMIRA PEN KIT 40 MG/0.8ML
adalimumab
BRAND
4
PA
HUMIRA PEN-CROHNS STARTER KIT 40
MG/0.8ML
adalimumab
BRAND
4
PA
HUMIRA PEN-PSORIASIS STARTER KIT 40
MG/0.8ML
adalimumab
BRAND
4
PA
SIMPONI ARIA SOLUTION 50 MG/4ML
golimumab
BRAND
4
SIMPONI SOLN A-INJ 100 MG/ML
golimumab
BRAND
4
PA
SIMPONI SOLN A-INJ 50 MG/0.5ML
golimumab
BRAND
4
PA
SIMPONI SOLN PRSYR 100 MG/ML
golimumab
BRAND
4
PA
SIMPONI SOLN PRSYR 50 MG/0.5ML
golimumab
BRAND
4
PA
BRAND
4
PA
OTREXUP SOLN A-INJ 10 MG/0.4ML
methotrexate (antirheumatic)
BRAND
4
BRAND
4
*ANALGESICS - ANTI-INFLAMMATORY*
*Anti-TNF-alpha - Monoclonal Antibodies**
*Antirheumatic - Enzyme Inhibitors**
XELJANZ TAB 5 MG
tofacitinib citrate
*Antirheumatic Antimetabolites**
PAGE 8
PRODUCT DESCRIPTION
BRAND/GEN
TIER
BRAND
4
BRAND
4
RHEUMATREX TAB 2.5 MG
methotrexate sodium (antirheumatic)
BRAND
2
BRAND
4
ACTEMRA SOLN PRSYR 162 MG/0.9ML
tocilizumab
BRAND
4
ACTEMRA SOLUTION 200 MG/10ML
tocilizumab
BRAND
4
PA
tocilizumab
BRAND
4
PA
tocilizumab
BRAND
4
PA
CELEBREX CAP 100 MG
celecoxib
BRAND
3
ST
CELEBREX CAP 200 MG
celecoxib
BRAND
3
ST
CELEBREX CAP 400 MG
celecoxib
BRAND
3
ST
CELEBREX CAP 50 MG
celecoxib
BRAND
3
ST
diclofenac potassium tab 50 mg
generic
1
diclofenac sodium er tab er 24h 100 mg
generic
1
diclofenac sodium tab dr 25 mg
generic
1
generic
1
generic
1
diclofenac-misoprostol tab dr 50-0.2 mg
generic
1
diclofenac-misoprostol tab dr 75-0.2 mg
generic
1
etodolac cap 200 mg
generic
1
etodolac cap 300 mg
generic
1
*Interleukin-1beta Blockers**
ILARIS RECON SOLN 180 MG
canakinumab
PA
*Interleukin-6 Receptor Inhibitors**
*Nonsteroidal Anti-inflammatory Agents (NSAIDs)**
PAGE 9
PRODUCT DESCRIPTION
BRAND/GEN
etodolac tab 400 mg
generic
1
etodolac tab 500 mg
generic
1
fenoprofen calcium tab 600 mg
generic
1
flurbiprofen tab 100 mg
generic
1
flurbiprofen tab 50 mg
generic
1
ibuprofen tab 400 mg
generic
1
generic
1
generic
1
INDOCIN SUSPENSION 25 MG/5ML
indomethacin
BRAND
3
indomethacin cap 25 mg
generic
1
indomethacin cap 50 mg
generic
1
ketoprofen cap 50 mg
generic
1
ketoprofen cap 75 mg
generic
1
ketorolac tromethamine solution 15 mg/ml
generic
1
ketorolac tromethamine solution 300 mg/10ml
generic
1
ketorolac tromethamine solution 60 mg/2ml
generic
1
ketorolac tromethamine tab 10 mg
generic
1
meclofenamate sodium cap 100 mg
generic
1
meclofenamate sodium cap 50 mg
generic
1
mefenamic acid cap 250 mg
generic
1
meloxicam 15 mg
generic
1
meloxicam 7.5 mg
generic
1
meloxicam suspension 7.5 mg/5ml
generic
1
meloxicam tab 15 mg
generic
1
meloxicam tab 7.5 mg
generic
1
nabumetone tab 500 mg
generic
1
nabumetone tab 750 mg
generic
1
naproxen dr tab dr 375 mg
generic
1
naproxen dr tab dr 500 mg
generic
1
naproxen sodium tab 550 mg
generic
1
naproxen tab 250 mg
generic
1
naproxen tab 375 mg
generic
1
PAGE 10
TIER
QL
20 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
TIER
naproxen tab 500 mg
generic
1
oxaprozin tab 600 mg
generic
1
piroxicam cap 10 mg
generic
1
piroxicam cap 20 mg
generic
1
sulindac tab 150 mg
generic
1
sulindac tab 200 mg
generic
1
tolmetin sodium cap 400 mg
generic
1
tolmetin sodium tab 200 mg
generic
1
tolmetin sodium tab 600 mg
generic
1
OTEZLA TAB 30 MG
apremilast
BRAND
4
OTEZLA TAB THPK 10 & 20 & 30 MG
apremilast
BRAND
4
leflunomide tab 10 mg
generic
1
leflunomide tab 20 mg
generic
1
ORENCIA RECON SOLN 250 MG
abatacept
BRAND
4
PA
ORENCIA SOLN PRSYR 125 MG/ML
abatacept
BRAND
4
PA
ENBREL KIT 25 MG
etanercept
BRAND
4
ENBREL SOLN PRSYR 25 MG/0.5ML
etanercept
BRAND
4
PA
ENBREL SOLN PRSYR 50 MG/ML
etanercept
BRAND
4
PA
ENBREL SURECLICK SOLN A-INJ 50 MG/ML
etanercept
BRAND
4
PA
alagesic cap 50-325-40 mg
generic
1
MDD
butalbital compound/asa tab 50-325-40 mg
generic
1
*Phosphodiesterase 4 (PDE4) Inhibitors**
*Pyrimidine Synthesis Inhibitors**
*Selective Costimulation Modulators**
*Soluble Tumor Necrosis Factor Receptor Agents**
*ANALGESICS - NonNarcotic*
*Analgesic Combinations**
PAGE 11
12 per day
PRODUCT DESCRIPTION
BRAND/GEN
TIER
butalbital-acetaminophen tab 50-325 mg
generic
1
MDD
12 per day
butalbital-apap-caffeine cap 50-325-40 mg
generic
1
MDD
12 per day
butalbital-apap-caffeine tab 50-325-40 mg
generic
1
MDD
12 per day
butalbital-asa-caffeine cap 50-325-40 mg
generic
1
butalbital-aspirin-caffeine cap 50-325-40 mg
generic
1
butalbital-aspirin-caffeine tab 50-325-40 mg
generic
1
PRIALT SOLUTION 500 MCG/20ML
ziconotide acetate
BRAND
4
PRIALT SOLUTION 500 MCG/5ML
ziconotide acetate
BRAND
4
generic
1
codeine sulfate solution 30 mg/5ml
generic
1
MDD
2 per day
codeine sulfate tab 15 mg
generic
1
MDD
2 per day
generic
1
MDD
2 per day
generic
1
MDD
2 per day
EXALGO TB24 DETER 32 MG
hydromorphone hcl
BRAND
3
fentanyl citrate loz handle 1200 mcg
generic
1
QL
90 / 30 days
generic
1
QL
90 / 30 days
generic
1
QL
90 / 30 days
generic
1
QL
90 / 30 days
generic
1
QL
90 / 30 days
generic
1
QL
90 / 30 days
fentanyl patch 72hr 100 mcg/hr
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
*Analgesics-Peptide Channel Blockers**
*Salicylates**
diflunisal tab 500 mg
*ANALGESICS - OPIOID*
*Opioid Agonists**
PAGE 12
QL
60 / 30 days
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
1
QL
hydromorphone hcl er tb24 deter 12 mg
generic
1
PA
generic
1
PA
HYDROMORPHONE HCL ER TB24 DETER
32 MG
hydromorphone hcl
BRAND
1
PA
generic
1
PA
hydromorphone hcl pf solution 1 mg/ml
generic
4
PA
generic
4
PA
generic
4
PA
generic
4
PA
hydromorphone hcl pf solution 50 mg/5ml
generic
4
PA
hydromorphone hcl pf solution 500 mg/50ml
generic
4
PA
hydromorphone hcl tab 2 mg
generic
1
QL
180 / 30 days
generic
1
QL
180 / 30 days
generic
1
QL
180 / 30 days
levorphanol tartrate tab 2 mg
generic
1
meperidine hcl tab 100 mg
generic
1
QL
180 / 30 days
meperidine hcl tab 50 mg
generic
1
QL
180 / 30 days
meperitab tab 100 mg
generic
1
QL
180 / 30 days
meperitab tab 50 mg
generic
1
QL
180 / 30 days
methadone hcl tab 10 mg
generic
1
QL
180 / 30 days
methadone hcl tab 5 mg
generic
1
QL
180 / 30 days
methadose tab 10 mg
generic
1
QL
180 / 30 days
morphine sulfate er beads cap er 24h 120 mg
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
30 / 30 days
1
PAGE 13
PRODUCT DESCRIPTION
BRAND/GEN
generic
generic
TIER
QL
30 / 30 days
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
morphine sulfate er cap er 24h 10 mg
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
morphine sulfate er tab er 100 mg
generic
1
QL
90 / 30 days
generic
1
QL
90 / 30 days
generic
1
QL
90 / 30 days
generic
1
QL
90 / 30 days
generic
1
QL
90 / 30 days
morphine sulfate suppos 30 mg
generic
1
QL
120 / 30 days
morphine sulfate tab 15 mg
generic
1
QL
120 / 30 days
morphine sulfate tab 30 mg
generic
1
QL
120 / 30 days
NUCYNTA ER TAB ER 12H 100 MG
tapentadol hcl
QL
BRAND
60 / 30 days
3
tapentadol hcl
BRAND
tapentadol hcl
BRAND
tapentadol hcl
BRAND
tapentadol hcl
BRAND
PA
QL
60 / 30 days
3
PA
QL
60 / 30 days
3
PA
QL
60 / 30 days
3
PA
QL
60 / 30 days
3
PA
3
PAGE 14
PRODUCT DESCRIPTION
BRAND/GEN
NUCYNTA TAB 100 MG
tapentadol hcl
BRAND
NUCYNTA TAB 50 MG
tapentadol hcl
BRAND
NUCYNTA TAB 75 MG
tapentadol hcl
BRAND
OPANA ER TAB ER 12H 10 MG
oxymorphone hcl
BRAND
oxymorphone hcl
BRAND
oxymorphone hcl
BRAND
oxymorphone hcl
BRAND
oxymorphone hcl
BRAND
oxymorphone hcl
BRAND
OPANA ER TAB ER 12H 7.5 MG
oxymorphone hcl
BRAND
OPANA ER TB12 DETER 10 MG
oxymorphone hcl
BRAND
oxymorphone hcl
BRAND
oxymorphone hcl
BRAND
oxymorphone hcl
BRAND
oxymorphone hcl
BRAND
BRAND
PAGE 15
TIER
QL
90 / 30 days
PA
QL
90 / 30 days
3
PA
QL
90 / 30 days
3
PA
QL
60 / 30 days
3
PA
QL
60 / 30 days
3
PA
QL
60 / 30 days
3
PA
QL
60 / 30 days
3
PA
QL
60 / 30 days
3
PA
QL
60 / 30 days
3
PA
QL
60 / 30 days
3
PA
QL
60 / 30 days
2
PA
QL
60 / 30 days
2
PA
QL
60 / 30 days
2
PA
QL
60 / 30 days
2
PA
QL
60 / 30 days
2
PA
2
QL
60 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
TIER
oxymorphone hcl
PA
QL
60 / 30 days
OPANA ER TB12 DETER 7.5 MG
oxymorphone hcl
BRAND
oxycodone hcl cap 5 mg
generic
1
QL
180 / 30 days
oxycodone hcl tab 10 mg
generic
1
QL
180 / 30 days
generic
1
QL
180 / 30 days
generic
1
QL
180 / 30 days
generic
1
QL
180 / 30 days
generic
1
QL
180 / 30 days
OXYCONTIN TB12 DETER 10 MG
oxycodone hcl
BRAND
3
oxycodone hcl
BRAND
oxycodone hcl
BRAND
oxycodone hcl
BRAND
oxycodone hcl
BRAND
oxycodone hcl
BRAND
oxycodone hcl
BRAND
oxymorphone hcl er tab er 12h 10 mg
generic
2
PA
PA
MDD
2 per day
PA
3
MDD
2 per day
PA
3
MDD
2 per day
PA
3
MDD
2 per day
PA
3
MDD
2 per day
PA
3
MDD
2 per day
PA
3
MDD
QL
2 per day
60 / 30 days
3
PA
QL
generic
60 / 30 days
3
PA
QL
generic
60 / 30 days
3
PA
PAGE 16
generic
3
QL
60 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
TIER
PA
QL
generic
60 / 30 days
3
PA
QL
generic
60 / 30 days
3
PA
QL
oxymorphone hcl er tab er 12h 7.5 mg
generic
60 / 30 days
3
PA
QL
oxymorphone hcl tab 10 mg
generic
120 / 30 days
3
PA
QL
oxymorphone hcl tab 5 mg
generic
120 / 30 days
3
PA
tramadol hcl 50 mg
generic
1
QL
240 / 30 days
tramadol hcl er (biphasic) tab er 24h 100 mg
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
tramadol hcl er tab er 24h 100 mg
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
tramadol hcl tab 50 mg
generic
1
QL
240 / 30 days
QL
generic
4 / day
1
*Opioid Combinations**
acetaminophen-codeine #2 tab 300-15 mg
generic
1
generic
1
MDD
6 per day
MDD
6 per day
QL
acetaminophen-codeine solution 120-12
mg/5ml
generic
1
acetaminophen-codeine tab 300-15 mg
generic
1
generic
1
generic
1
PAGE 17
4 / day
MDD
6 per day
MDD
30 per day
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ascomp-codeine cap 50-325-40-30 mg
generic
1
butalbital compound/codeine cap 50-325-40-30
mg
generic
1
butalbital-apap-caff-cod cap 50-325-40-30 mg
generic
1
butalbital-asa-caff-codeine cap 50-325-40-30
mg
generic
1
hydrocodone-acetaminophen 5-325 mg
generic
hydrocodone-acetaminophen solution 10-325
mg/15ml
MDD
12 per day
1
MDD
12 per day
generic
1
MDD
180 per day
hydrocodone-acetaminophen solution 2.5-108
mg/5ml
generic
1
MDD
180 per day
hydrocodone-acetaminophen solution 5-217
mg/10ml
generic
1
MDD
180 per day
mg/15ml
generic
1
MDD
180 per day
mg/15ml
generic
1
MDD
120 per day
hydrocodone-acetaminophen tab 10-300 mg
generic
1
MDD
12 per day
generic
1
MDD
12 per day
generic
1
MDD
8 per day
generic
1
MDD
6 per day
generic
1
MDD
6 per day
generic
1
MDD
5 per day
HYDROCODONE-ACETAMINOPHEN TAB 10750 MG
hydrocodone-acetaminophen
BRAND
2
MDD
5 per day
hydrocodone-acetaminophen tab 2.5-325 mg
generic
1
MDD
12 per day
HYDROCODONE-ACETAMINOPHEN TAB
2.5-325 MG
BRAND
2
MDD
12 per day
generic
1
MDD
8 per day
generic
1
MDD
12 per day
generic
1
MDD
12 per day
generic
1
MDD
8 per day
PAGE 18
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
1
MDD
12 per day
generic
1
MDD
12 per day
7.5-500 MG
BRAND
2
MDD
8 per day
generic
1
MDD
6 per day
7.5-650 MG
BRAND
2
MDD
6 per day
generic
1
MDD
5 per day
hydrocodone-ibuprofen tab 7.5-200 mg
generic
1
oxycodone-acetaminophen cap 5-500 mg
generic
1
MDD
6 per day
oxycodone-acetaminophen tab 10-325 mg
generic
1
MDD
6 per day
generic
1
MDD
6 per day
oxycodone-acetaminophen tab 2.5-325 mg
generic
1
MDD
6 per day
generic
1
MDD
6 per day
generic
1
MDD
6 per day
generic
1
MDD
6 per day
oxycodone-ibuprofen tab 5-400 mg
generic
1
tramadol-acetaminophen tab 37.5-325 mg
generic
1
generic
1
QL
4 / day
QL
90 / 30 days
*Opioid Partial Agonists**
buprenorphine hcl sl tab 2 mg
PA
QL
buprenorphine hcl sl tab 8 mg
generic
90 / 30 days
1
PA
QL
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg
generic
90 / 30 days
1
PA
QL
buprenorphine hcl-naloxone hcl sl tab 8-2 mg
generic
90 / 30 days
1
PA
butorphanol tartrate solution 10 mg/ml
generic
1
BUTRANS PATCH WK 10 MCG/HR
BRAND
3
PAGE 19
QL
4 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
TIER
buprenorphine
buprenorphine
BRAND
3
QL
4 / 30 days
buprenorphine
BRAND
3
QL
4 / 30 days
buprenorphine
BRAND
3
QL
4 / 30 days
pentazocine-naloxone hcl tab 50-0.5 mg
generic
1
SUBOXONE FILM 12-3 MG
buprenorphine hcl-naloxone hcl dihydrate
BRAND
2
PA
SUBOXONE FILM 2-0.5 MG
BRAND
2
PA
BRAND
2
PA
BRAND
2
PA
SUBOXONE SL TAB 2-0.5 MG
BRAND
2
PA
ANADROL-50 TAB 50 MG
oxymetholone
BRAND
3
oxandrolone tab 10 mg
generic
1
oxandrolone tab 2.5 mg
generic
1
ANDRODERM PATCH 24HR 2 MG/24HR
testosterone
BRAND
2
ANDRODERM PATCH 24HR 2.5 MG/24HR
testosterone
BRAND
2
testosterone
BRAND
2
testosterone
BRAND
2
ANDROGEL GEL 20.25 MG/1.25GM (1.62%)
testosterone
BRAND
2
ANDROGEL GEL 25 MG/2.5GM
testosterone
BRAND
2
ANDROGEL GEL 40.5 MG/2.5GM (1.62%)
BRAND
2
*ANDROGENS-ANABOLIC*
*Anabolic Steroids**
*Androgens**
PAGE 20
PRODUCT DESCRIPTION
BRAND/GEN
TIER
testosterone
ANDROGEL GEL 50 MG/5GM
testosterone
BRAND
2
ANDROGEL PUMP GEL 12.5 MG/ACT (1%)
testosterone
BRAND
2
ANDROGEL PUMP GEL 20.25 MG/ACT
(1.62%)
testosterone
BRAND
2
ANDROID CAP 10 MG
methyltestosterone
BRAND
3
ANDROXY TAB 10 MG
fluoxymesterone
BRAND
3
danazol cap 100 mg
generic
1
danazol cap 200 mg
generic
1
danazol cap 50 mg
generic
1
METHITEST TAB 10 MG
methyltestosterone
BRAND
3
testosterone cypionate solution 100 mg/ml
generic
1
testosterone cypionate solution 200 mg/ml
generic
1
testosterone enanthate solution 200 mg/ml
generic
1
TESTRED CAP 10 MG
methyltestosterone
BRAND
3
colocort enema 100 mg/60ml
generic
1
hydrocortisone enema 100 mg/60ml
generic
1
hc pram cream 1-1 %
generic
1
hc pram cream 2.5-1 %
generic
1
hydrocortisone ace-pramoxine cream 1-1 %
generic
1
hydrocortisone ace-pramoxine cream 2.5-1 %
generic
1
pramcort cream 1-1 %
generic
1
anucort-hc suppos 25 mg
generic
1
grx hicort 25 suppos 25 mg
generic
1
*ANORECTAL AGENTS*
*Intrarectal Steroids**
*Rectal Combinations**
*Rectal Steroids**
PAGE 21
PRODUCT DESCRIPTION
BRAND/GEN
TIER
hemorrhoidal-hc suppos 25 mg
generic
1
hemril-30 suppos 30 mg
generic
1
hydrocortisone acetate suppos 25 mg
generic
1
hydrocortisone acetate suppos 30 mg
generic
1
hydrocortisone cream 2.5 %
generic
1
proctocare-hc cream 2.5 %
generic
1
proctocream hc cream 2.5 %
generic
1
proctosol hc cream 2.5 %
generic
1
proctozone-hc cream 2.5 %
generic
1
rectacort-hc suppos 25 mg
generic
1
BRAND
3
ALBENZA TAB 200 MG
albendazole
BRAND
3
BILTRICIDE TAB 600 MG
praziquantel
BRAND
3
mebendazole chew tab 100 mg
generic
3
STROMECTOL TAB 3 MG
ivermectin
BRAND
3
PA
aztreonam recon soln 1 gm
generic
1
PA
aztreonam recon soln 2 gm
generic
1
PA
CAYSTON RECON SOLN 75 MG
aztreonam lysine
BRAND
4
PA
colistimethate sodium recon soln 150 mg
generic
4
PA
FIRST-VANCOMYCIN 25 SOLUTION 25
MG/ML
vancomycin hcl
BRAND
2
FIRST-VANCOMYCIN 50 SOLUTION 50
MG/ML
vancomycin hcl
BRAND
2
*Vasodilating Agents**
RECTIV OINTMENT 0.4 %
nitroglycerin (intra-anal)
*ANTHELMINTICS*
*Anthelmintics**
PA
*ANTI-INFECTIVE AGENTS - MISC.*
*Anti-infective Agents - Misc.**
PAGE 22
PRODUCT DESCRIPTION
BRAND/GEN
FLAGYL ER TAB ER 24H 750 MG
metronidazole
BRAND
3
metronidazole cap 375 mg
generic
1
metronidazole in nacl solution 5-0.79 mg/ml-%
generic
4
PA
metronidazole in nacl solution 500-0.79
mg/100ml-%
generic
4
PA
metronidazole tab 250 mg
generic
1
metronidazole tab 500 mg
generic
1
NEBUPENT RECON SOLN 300 MG
pentamidine isethionate
BRAND
3
PA
PENTAM RECON SOLN 300 MG
pentamidine isethionate
BRAND
3
PA
trimethoprim tab 100 mg
generic
1
vancomycin hcl cap 125 mg
generic
3
QL
40 / 30 days
vancomycin hcl cap 250 mg
generic
3
QL
40 / 30 days
VANCOMYCIN HCL IN DEXTROSE
SOLUTION 1 GM/200ML
vancomycin hcl in dextrose
BRAND
3
PA
SOLUTION 500 MG/100ML
BRAND
3
PA
SOLUTION 750 MG/150ML
BRAND
3
PA
vancomycin hcl recon soln 10 gm
generic
3
PA
vancomycin hcl recon soln 1000 mg
generic
3
PA
generic
3
PA
generic
3
PA
VANCOMYCIN HCL RECON SOLN 750 MG
vancomycin hcl
BRAND
3
PA
VIBATIV RECON SOLN 250 MG
telavancin hcl
BRAND
3
PA
VIBATIV RECON SOLN 750 MG
telavancin hcl
BRAND
3
PA
XIFAXAN TAB 200 MG
rifaximin
BRAND
3
PA
XIFAXAN TAB 550 MG
BRAND
3
PA
PAGE 23
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
rifaximin
*Anti-infective Misc. - Combinations**
e.s.p. recon susp 200-600 mg/5ml
generic
1
erythromycin-sulfisoxazole recon susp 200-600
mg/5ml
generic
1
smz-tmp ds tab 800-160 mg
generic
1
sulfamethoxazole-tmp ds tab 800-160 mg
generic
1
sulfamethoxazole-trimethoprim solution 400-80
mg/5ml
generic
1
sulfamethoxazole-trimethoprim suspension
200-40 mg/5ml
generic
1
sulfamethoxazole-trimethoprim suspension
800-160 mg/20ml
generic
1
sulfamethoxazole-trimethoprim tab 400-80 mg
generic
1
sulfatrim pediatric suspension 200-40 mg/5ml
generic
1
ALINIA RECON SUSP 100 MG/5ML
nitazoxanide
BRAND
3
ALINIA TAB 500 MG
nitazoxanide
BRAND
3
atovaquone suspension 750 mg/5ml
generic
1
BRAND
3
PA
BRAND
3
PA
BRAND
3
PA
KETEK TAB 300 MG
telithromycin
BRAND
3
KETEK TAB 400 MG
telithromycin
BRAND
3
PA
*Antiprotozoal Agents**
*Carbapenems**
DORIBAX RECON SOLN 250 MG
doripenem
*Cyclic Lipopeptides**
CUBICIN RECON SOLN 500 MG
daptomycin
*Glycylcyclines**
TYGACIL RECON SOLN 50 MG
tigecycline
*Ketolides**
*Leprostatics**
PAGE 24
PRODUCT DESCRIPTION
BRAND/GEN
TIER
dapsone tab 100 mg
generic
1
dapsone tab 25 mg
generic
1
clindamycin hcl cap 150 mg
generic
1
generic
1
generic
1
clindamycin palmitate hcl recon soln 75 mg/5ml
generic
1
clindamycin phosphate in d5w solution 300
mg/50ml
generic
1
PA
mg/50ml
generic
1
PA
mg/50ml
generic
1
PA
clindamycin phosphate solution 300 mg/2ml
generic
1
PA
CLINDAMYCIN PHOSPHATE SOLUTION 300
MG/2ML
clindamycin phosphate
BRAND
2
PA
generic
1
PA
clindamycin phosphate solution 9 gm/60ml
generic
1
PA
generic
1
PA
generic
1
PA
LINCOCIN SOLUTION 300 MG/ML
lincomycin hcl
BRAND
3
PA
ZYVOX RECON SUSP 100 MG/5ML
linezolid
BRAND
2
PA
ZYVOX SOLUTION 2 MG/ML
linezolid
BRAND
2
PA
ZYVOX TAB 600 MG
linezolid
BRAND
2
PA
generic
1
PA
*Lincosamides**
*Oxazolidinones**
*Polymyxins**
polymyxin b sulfate recon soln 500000 unit
*ANTIANGINAL AGENTS*
*Antianginals-Other**
PAGE 25
PRODUCT DESCRIPTION
BRAND/GEN
TIER
RANEXA TAB ER 12H 1000 MG
ranolazine
BRAND
3
PA
RANEXA TAB ER 12H 500 MG
ranolazine
BRAND
3
PA
isochron tab er 40 mg
generic
1
isoditrate er tab er 40 mg
generic
1
isosorbide dinitrate er tab er 40 mg
generic
1
isosorbide dinitrate sl tab 2.5 mg
generic
1
isosorbide dinitrate sl tab 5 mg
generic
1
isosorbide dinitrate tab 10 mg
generic
1
generic
1
generic
1
generic
1
isosorbide mononitrate er tab er 24h 120 mg
generic
1
generic
1
generic
1
isosorbide mononitrate tab 10 mg
generic
1
isosorbide mononitrate tab 20 mg
generic
1
meloxicam tab 15 mg
generic
1
minitran patch 24hr 0.1 mg/hr
generic
1
generic
1
generic
1
generic
1
NITRO-BID OINTMENT 2 %
nitroglycerin
BRAND
3
nitro-time cap er 2.5 mg
generic
1
nitro-time cap er 6.5 mg
generic
1
nitro-time cap er 9 mg
generic
1
nitroglycerin aero soln 400 mcg/spray
generic
1
nitroglycerin er cap er 2.5 mg
generic
1
nitroglycerin er cap er 6.5 mg
generic
1
nitroglycerin er cap er 9 mg
generic
1
*Nitrates**
1
PAGE 26
PRODUCT DESCRIPTION
BRAND/GEN
TIER
nitroglycerin patch 24hr 0.1 mg/hr
generic
generic
1
generic
1
generic
1
NITROSTAT SL TAB 0.3 MG
nitroglycerin
BRAND
2
nitroglycerin
BRAND
2
nitroglycerin
BRAND
2
buspirone hcl tab 10 mg
generic
1
generic
1
generic
1
generic
1
buspirone hcl tab 7.5 mg
generic
1
hydroxyzine hcl solution 10 mg/5ml
generic
1
hydroxyzine hcl syrup 10 mg/5ml
generic
1
hydroxyzine hcl tab 10 mg
generic
1
generic
1
generic
1
hydroxyzine pamoate 25 mg
generic
1
hydroxyzine pamoate cap 100 mg
generic
1
generic
1
generic
1
meprobamate tab 200 mg
generic
1
meprobamate tab 400 mg
generic
1
alprazolam er tab er 24h 0.5 mg
generic
1
QL
30 / 30 days
alprazolam er tab er 24h 1 mg
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
*ANTIANXIETY AGENTS*
*Antianxiety Agents - Misc.**
*Benzodiazepines**
PAGE 27
PRODUCT DESCRIPTION
BRAND/GEN
TIER
alprazolam tab 0.25 mg
generic
1
QL
120 / 30 days
alprazolam tab 0.5 mg
generic
1
QL
120 / 30 days
alprazolam tab 1 mg
generic
1
QL
120 / 30 days
alprazolam tab 2 mg
generic
1
QL
120 / 30 days
alprazolam tab disp 0.25 mg
generic
1
QL
120 / 30 days
alprazolam tab disp 0.5 mg
generic
1
QL
120 / 30 days
alprazolam tab disp 1 mg
generic
1
QL
120 / 30 days
alprazolam tab disp 2 mg
generic
1
QL
120 / 30 days
alprazolam xr tab er 24h 0.5 mg
generic
1
QL
30 / 30 days
alprazolam xr tab er 24h 1 mg
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
diazepam tab 10 mg
generic
1
QL
2 / 30 days
diazepam tab 2 mg
generic
1
QL
120 / 30 days
diazepam tab 5 mg
generic
1
QL
120 / 30 days
lorazepam solution 4 mg/ml
generic
1
QL
8 / 30 days
lorazepam tab 0.5 mg
generic
1
QL
120 / 30 days
lorazepam tab 1 mg
generic
1
QL
120 / 30 days
lorazepam tab 2 mg
generic
1
QL
120 / 30 days
disopyramide phosphate cap 100 mg
generic
1
disopyramide phosphate cap 150 mg
generic
1
LIDOCAINE HCL (CARDIAC) SOLUTION 10
MG/ML
lidocaine hcl (cardiac)
BRAND
2
PA
lidocaine hcl (cardiac) solution 20 mg/ml
generic
1
PA
*ANTIARRHYTHMICS*
*Antiarrhythmics Type I-A**
*Antiarrhythmics Type I-B**
PAGE 28
PRODUCT DESCRIPTION
BRAND/GEN
TIER
lidocaine in d5w solution 4-5 mg/ml-%
generic
1
PA
lidocaine in d5w solution 8-5 mg/ml-%
generic
1
PA
mexiletine hcl cap 150 mg
generic
1
generic
1
generic
1
flecainide acetate tab 100 mg
generic
1
generic
1
generic
1
propafenone hcl er cap er 12h 225 mg
generic
1
propafenone hcl er cap er 12h 325 mg
generic
1
propafenone hcl tab 150 mg
generic
1
propafenone hcl tab 300 mg
generic
1
amiodarone hcl tab 100 mg
generic
3
generic
1
generic
1
MULTAQ TAB 400 MG
dronedarone hcl
BRAND
4
TIKOSYN CAP 125 MCG
dofetilide
BRAND
2
PA
TIKOSYN CAP 250 MCG
dofetilide
BRAND
2
PA
TIKOSYN CAP 500 MCG
dofetilide
BRAND
2
PA
*Antiarrhythmics Type I-C**
*Antiarrhythmics Type III**
*ANTIASTHMATIC AND BRONCHODILATOR AGENTS*
*Anti-Inflammatory Agents**
cromolyn sodium nebu soln 20 mg/2ml
generic
1
BRAND
4
BRAND
3
*Antiasthmatic - Monoclonal Antibodies**
XOLAIR RECON SOLN 150 MG
omalizumab
PA
*Bronchodilators - Anticholinergics**
ATROVENT HFA AERO SOLN 17 MCG/ACT
ipratropium bromide hfa
PAGE 29
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ipratropium bromide solution 0.02 %
generic
1
SPIRIVA HANDIHALER CAP 18 MCG
tiotropium bromide monohydrate
BRAND
3
montelukast sodium chew tab 4 mg
generic
1
QL
30 / 30 days
montelukast sodium chew tab 5 mg
generic
1
QL
30 / 30 days
montelukast sodium packet 4 mg
generic
1
QL
30 / 30 days
montelukast sodium tab 10 mg
generic
1
QL
30 / 30 days
zafirlukast tab 10 mg
generic
1
QL
60 / 30 days
zafirlukast tab 20 mg
generic
1
QL
60 / 30 days
ZYFLO CR TAB ER 12H 600 MG
zileuton
BRAND
3
PA
ZYFLO TAB 600 MG
zileuton
BRAND
3
PA
ASMANEX 120 METERED DOSES AER POW
BA 220 MCG/INH
mometasone furoate (inhalation)
BRAND
3
BA 220 MCG/INH
BRAND
3
BA 110 MCG/INH
BRAND
3
BA 220 MCG/INH
BRAND
3
BA 220 MCG/INH
BRAND
3
BA 110 MCG/INH
BRAND
3
budesonide suspension 0.25 mg/2ml
generic
1
budesonide suspension 0.5 mg/2ml
generic
1
FLOVENT DISKUS AER POW BA 250
MCG/BLIST
fluticasone propionate (inhalation)
BRAND
2
*Leukotriene Modulators**
*Steroid Inhalants**
PAGE 30
PRODUCT DESCRIPTION
BRAND/GEN
TIER
FLOVENT HFA AEROSOL 110 MCG/ACT
fluticasone propionate hfa
BRAND
3
BRAND
3
BRAND
3
PULMICORT FLEXHALER AER POW BA 180
MCG/ACT
budesonide (inhalation)
BRAND
3
PULMICORT FLEXHALER AER POW BA 90
MCG/ACT
BRAND
3
PULMICORT SUSPENSION 1 MG/2ML
BRAND
3
QVAR AERO SOLN 40 MCG/ACT
beclomethasone dipropionate
BRAND
3
QVAR AERO SOLN 80 MCG/ACT
beclomethasone dipropionate
BRAND
3
ADVAIR DISKUS AER POW BA 100-50
MCG/DOSE
fluticasone-salmeterol
BRAND
2
MCG/DOSE
BRAND
2
MCG/DOSE
BRAND
2
ADVAIR HFA AEROSOL 115-21 MCG/ACT
BRAND
2
BRAND
2
BRAND
2
albuterol sulfate nebu soln (5 mg/ml) 0.5%
generic
1
albuterol sulfate nebu soln 0.63 mg/3ml
generic
1
albuterol sulfate nebu soln 1.25 mg/3ml
generic
1
albuterol sulfate syrup 2 mg/5ml
generic
1
albuterol sulfate tab 2 mg
generic
1
albuterol sulfate tab 4 mg
generic
1
*Sympathomimetics**
PAGE 31
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ARCAPTA NEOHALER CAP 75 MCG
indacaterol maleate
BRAND
3
COMBIVENT RESPIMAT AERO SOLN 20-100
MCG/ACT
ipratropium-albuterol
BRAND
3
DULERA AEROSOL 100-5 MCG/ACT
mometasone furoate-formoterol fumarate
dihydrate
BRAND
3
DULERA AEROSOL 200-5 MCG/ACT
mometasone furoate-formoterol fumarate
dihydrate
BRAND
3
epinephrine hcl soln prsyr 0.1 mg/ml
generic
1
QL
1 / 30 days
PA
epinephrine hcl solution 1 mg/ml
generic
1
FORADIL AEROLIZER CAP 12 MCG
formoterol fumarate
BRAND
3
ipratropium-albuterol solution 0.5-2.5 (3)
mg/3ml
generic
1
levalbuterol hcl nebu soln 0.31 mg/3ml
generic
1
generic
1
levalbuterol hcl nebu soln 1.25 mg/0.5ml
generic
1
generic
1
MAXAIR AUTOHALER AERO BA 200
MCG/INH
pirbuterol acetate
BRAND
2
metaproterenol sulfate syrup 10 mg/5ml
generic
1
metaproterenol sulfate tab 10 mg
generic
1
metaproterenol sulfate tab 20 mg
generic
1
PERFOROMIST NEBU SOLN 20 MCG/2ML
formoterol fumarate
BRAND
3
PROAIR HFA AERO SOLN 108 (90 BASE)
MCG/ACT
albuterol sulfate
BRAND
1
PROVENTIL HFA AERO SOLN 108 (90 BASE)
MCG/ACT
albuterol sulfate
BRAND
1
SEREVENT DISKUS AER POW BA 50
MCG/DOSE
salmeterol xinafoate
BRAND
2
PA
3
PAGE 32
PRODUCT DESCRIPTION
BRAND/GEN
TIER
SYMBICORT AEROSOL 160-4.5 MCG/ACT
budesonide-formoterol fumarate dihydrate
BRAND
SYMBICORT AEROSOL 80-4.5 MCG/ACT
budesonide-formoterol fumarate dihydrate
BRAND
3
terbutaline sulfate tab 2.5 mg
generic
1
terbutaline sulfate tab 5 mg
generic
1
VENTOLIN HFA AERO SOLN 108 (90 BASE)
MCG/ACT
albuterol sulfate
BRAND
1
XOPENEX HFA AEROSOL 45 MCG/ACT
levalbuterol tartrate
BRAND
3
elixophyllin elixir 80 mg/15ml
generic
1
THEO-24 CAP ER 24H 100 MG
theophylline
BRAND
2
theophylline
BRAND
2
theophylline
BRAND
2
theophylline
BRAND
2
theochron tab er 12h 100 mg
generic
1
generic
1
generic
1
theophylline elixir 80 mg/15ml
generic
1
theophylline er tab er 12h 100 mg
generic
1
generic
1
generic
1
generic
1
generic
1
generic
1
theophylline solution 80 mg/15ml
generic
1
BRAND
2
*Xanthines**
*ANTICOAGULANTS*
*Coumarin Anticoagulants**
COUMADIN RECON SOLN 5 MG
warfarin sodium
PAGE 33
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
jantoven tab 1 mg
generic
1
jantoven tab 10 mg
generic
1
jantoven tab 2 mg
generic
1
jantoven tab 2.5 mg
generic
1
jantoven tab 3 mg
generic
1
jantoven tab 4 mg
generic
1
jantoven tab 5 mg
generic
1
jantoven tab 6 mg
generic
1
jantoven tab 7.5 mg
generic
1
warfarin sodium tab 1 mg
generic
1
generic
1
generic
1
warfarin sodium tab 2.5 mg
generic
1
generic
1
generic
1
generic
1
generic
1
warfarin sodium tab 7.5 mg
generic
1
ELIQUIS TAB 2.5 MG
apixaban
BRAND
3
PA
ELIQUIS TAB 5 MG
apixaban
BRAND
3
PA
XARELTO TAB 10 MG
rivaroxaban
BRAND
2
PA
XARELTO TAB 15 MG
rivaroxaban
BRAND
2
PA
XARELTO TAB 20 MG
rivaroxaban
BRAND
2
PA
generic
4
*Direct Factor Xa Inhibitors**
*Heparins And Heparinoid-Like Agents**
QL
enoxaparin sodium solution 100 mg/ml
60 / 30 days
PA
QL
enoxaparin sodium solution 120 mg/0.8ml
generic
60 / 30 days
4
PA
PAGE 34
PRODUCT DESCRIPTION
BRAND/GEN
enoxaparin sodium solution 150 mg/ml
generic
TIER
QL
60 / 30 days
4
PA
QL
generic
60 / 30 days
4
PA
QL
enoxaparin sodium solution 300 mg/3ml
generic
60 / 30 days
4
PA
QL
generic
60 / 30 days
4
PA
QL
generic
60 / 30 days
4
PA
QL
generic
60 / 30 days
4
PA
QL
FRAGMIN SOLUTION 10000 UNIT/ML
dalteparin sodium
BRAND
FRAGMIN SOLUTION 12500 UNIT/0.5ML
dalteparin sodium
BRAND
dalteparin sodium
BRAND
FRAGMIN SOLUTION 18000 UNT/0.72ML
dalteparin sodium
BRAND
dalteparin sodium
BRAND
FRAGMIN SOLUTION 25000 UNIT/ML
dalteparin sodium
BRAND
dalteparin sodium
BRAND
dalteparin sodium
BRAND
HEPARIN (PORCINE) IN NACL SOLUTION
100-0.45 UNIT/ML-%
heparin (porcine) in sodium chloride
BRAND
2
HEPARIN (PORCINE) IN NACL SOLUTION
BRAND
2
PAGE 35
30 / 30 days
4
PA
QL
30 / 30 days
4
PA
QL
30 / 30 days
4
PA
QL
30 / 30 days
4
PA
QL
30 / 30 days
4
PA
QL
30 / 30 days
4
PA
QL
30 / 30 days
4
PA
QL
30 / 30 days
4
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
50-0.45 UNIT/ML-%
heparin (porcine) in sodium chloride
heparin sodium (porcine) pf solution 5000
unit/0.5ml
generic
1
INNOHEP SOLUTION 20000 UNIT/ML
tinzaparin sodium
BRAND
4
PRADAXA CAP 150 MG
dabigatran etexilate mesylate
BRAND
3
PA
PRADAXA CAP 75 MG
dabigatran etexilate mesylate
BRAND
3
PA
clonazepam tab 0.5 mg
generic
1
QL
120 / 30 days
clonazepam tab 1 mg
generic
1
QL
120 / 30 days
clonazepam tab 2 mg
generic
1
QL
120 / 30 days
clonazepam tab disp 0.125 mg
generic
1
QL
120 / 30 days
generic
1
QL
120 / 30 days
generic
1
QL
120 / 30 days
clonazepam tab disp 1 mg
generic
1
QL
120 / 30 days
clonazepam tab disp 2 mg
generic
1
QL
120 / 30 days
diazepam gel 10 mg
generic
1
QL
2 / 30 days
diazepam gel 2.5 mg
generic
1
QL
2 / 30 days
diazepam gel 20 mg
generic
1
QL
2 / 30 days
carbamazepine chew tab 100 mg
generic
1
carbamazepine er cap er 12h 100 mg
generic
1
generic
1
generic
1
carbamazepine er tab er 12h 200 mg
generic
1
carbamazepine er tab er 12h 400 mg
generic
1
carbamazepine suspension 100 mg/5ml
generic
1
*Thrombin Inhibitors**
*ANTICONVULSANTS*
*Anticonvulsants - Benzodiazepines**
*Anticonvulsants - Misc.**
PAGE 36
PRODUCT DESCRIPTION
BRAND/GEN
carbamazepine tab 200 mg
generic
1
epitol tab 200 mg
generic
1
gabapentin 300 mg
generic
1
gabapentin 400 mg
generic
1
gabapentin cap 100 mg
generic
1
generic
1
generic
1
gabapentin solution 250 mg/5ml
generic
1
gabapentin tab 600 mg
generic
1
gabapentin tab 800 mg
generic
1
lamotrigine chew tab 25 mg
generic
1
lamotrigine chew tab 5 mg
generic
1
lamotrigine er tab er 24h 100 mg
generic
1
generic
1
generic
1
generic
1
generic
1
generic
1
lamotrigine tab 100 mg
generic
1
generic
1
generic
1
generic
1
levetiracetam er tab er 24h 500 mg
generic
1
levetiracetam er tab er 24h 750 mg
generic
1
levetiracetam tab 1000 mg
generic
1
generic
1
generic
1
generic
1
LYRICA CAP 100 MG
pregabalin
BRAND
3
LYRICA CAP 150 MG
pregabalin
BRAND
PAGE 37
TIER
QL
90 / 30 days
PA
QL
90 / 30 days
3
PA
PRODUCT DESCRIPTION
BRAND/GEN
LYRICA CAP 200 MG
pregabalin
BRAND
LYRICA CAP 225 MG
pregabalin
BRAND
LYRICA CAP 25 MG
pregabalin
BRAND
LYRICA CAP 300 MG
pregabalin
BRAND
LYRICA CAP 50 MG
pregabalin
BRAND
LYRICA CAP 75 MG
pregabalin
BRAND
LYRICA SOLUTION 20 MG/ML
pregabalin
BRAND
2
oxcarbazepine suspension 300 mg/5ml
generic
1
oxcarbazepine tab 150 mg
generic
1
generic
1
generic
1
primidone tab 250 mg
generic
1
primidone tab 50 mg
generic
1
TEGRETOL-XR TAB ER 12H 100 MG
carbamazepine
BRAND
3
topiragen tab 100 mg
generic
1
topiragen tab 200 mg
generic
1
topiragen tab 25 mg
generic
1
topiragen tab 50 mg
generic
1
topiramate cap sprink 15 mg
generic
1
topiramate cap sprink 25 mg
generic
1
topiramate tab 100 mg
generic
1
generic
1
generic
1
generic
1
VIMPAT SOLUTION 10 MG/ML
BRAND
3
PAGE 38
TIER
QL
90 / 30 days
3
PA
QL
90 / 30 days
3
PA
QL
90 / 30 days
3
PA
QL
90 / 30 days
3
PA
QL
90 / 30 days
3
PA
QL
90 / 30 days
3
PA
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
lacosamide
VIMPAT SOLUTION 200 MG/20ML
lacosamide
BRAND
2
VIMPAT TAB 100 MG
lacosamide
BRAND
3
PA
VIMPAT TAB 150 MG
lacosamide
BRAND
3
PA
VIMPAT TAB 200 MG
lacosamide
BRAND
3
PA
VIMPAT TAB 50 MG
lacosamide
BRAND
3
PA
zonisamide cap 100 mg
generic
1
generic
1
generic
1
felbamate suspension 600 mg/5ml
generic
3
felbamate tab 400 mg
generic
3
felbamate tab 600 mg
generic
3
GABITRIL TAB 12 MG
tiagabine hcl
BRAND
2
GABITRIL TAB 16 MG
tiagabine hcl
BRAND
2
SABRIL PACKET 500 MG
vigabatrin
BRAND
4
PA
SABRIL TAB 500 MG
vigabatrin
BRAND
4
PA
tiagabine hcl tab 2 mg
generic
1
tiagabine hcl tab 4 mg
generic
1
DILANTIN CAP 30 MG
phenytoin sodium extended
BRAND
2
DILANTIN INFATABS CHEW TAB 50 MG
phenytoin
BRAND
2
phenytoin chew tab 50 mg
generic
1
phenytoin infatabs chew tab 50 mg
generic
1
*Carbamates**
*GABA Modulators**
*Hydantoins**
1
PAGE 39
PRODUCT DESCRIPTION
BRAND/GEN
TIER
phenytoin sodium extended cap 100 mg
generic
generic
1
generic
1
phenytoin suspension 100 mg/4ml
generic
1
phenytoin suspension 125 mg/5ml
generic
1
ethosuximide cap 250 mg
generic
1
ethosuximide solution 250 mg/5ml
generic
1
divalproex sodium cap sprink 125 mg
generic
1
divalproex sodium er tab er 24h 250 mg
generic
1
divalproex sodium er tab er 24h 500 mg
generic
1
divalproex sodium tab dr 125 mg
generic
1
generic
1
generic
1
valproate sodium solution 100 mg/ml
generic
1
PA
valproate sodium solution 500 mg/5ml
generic
1
PA
valproic acid cap 250 mg
generic
1
mirtazapine tab 15 mg
generic
1
generic
1
generic
1
mirtazapine tab 7.5 mg
generic
1
mirtazapine tab disp 15 mg
generic
1
generic
1
generic
1
budeprion sr tab er 12h 100 mg
generic
1
QL
60 / 30 days
budeprion sr tab er 12h 150 mg
generic
1
QL
60 / 30 days
budeprion xl tab er 24h 150 mg
generic
1
QL
60 / 30 days
*Succinimides**
*Valproic Acid**
*ANTIDEPRESSANTS*
*Alpha-2 Receptor Antagonists (Tetracyclics)**
*Antidepressants - Misc.**
PAGE 40
PRODUCT DESCRIPTION
BRAND/GEN
TIER
budeprion xl tab er 24h 300 mg
generic
1
QL
60 / 30 days
bupropion hcl er (sr) tab er 12h 100 mg
generic
1
QL
60 / 30 days
generic
1
QL
60 / 30 days
generic
1
QL
60 / 30 days
bupropion hcl er (xl) tab er 24h 150 mg
generic
1
QL
60 / 30 days
bupropion hcl er (xl) tab er 24h 300 mg
generic
1
QL
60 / 30 days
bupropion hcl tab 100 mg
generic
1
bupropion hcl tab 75 mg
generic
1
maprotiline hcl tab 25 mg
generic
1
generic
1
generic
1
EMSAM PATCH 24HR 12 MG/24HR
selegiline
BRAND
3
selegiline
BRAND
3
selegiline
BRAND
3
MARPLAN TAB 10 MG
isocarboxazid
BRAND
3
phenelzine sulfate tab 15 mg
generic
1
tranylcypromine sulfate tab 10 mg
generic
1
citalopram hydrobromide tab 10 mg
generic
1
QL
45 / 30 days
generic
1
QL
45 / 30 days
generic
1
QL
45 / 30 days
escitalopram oxalate tab 10 mg
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
fluoxetine hcl cap 10 mg
generic
1
generic
1
*Monoamine Oxidase Inhibitors (MAOIs)**
*Selective Serotonin Reuptake Inhibitors (SSRIs)**
1
PAGE 41
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
fluoxetine hcl cap dr 90 mg
generic
1
fluoxetine hcl tab 10 mg
generic
1
generic
1
generic
1
fluvoxamine maleate er cap er 24h 100 mg
generic
1
fluvoxamine maleate er cap er 24h 150 mg
generic
1
fluvoxamine maleate tab 100 mg
generic
1
generic
1
generic
1
paroxetine hcl 30 mg
generic
1
QL
45 / 30 days
paroxetine hcl 40 mg
generic
1
QL
45 / 30 days
paroxetine hcl er tab er 24h 12.5 mg
generic
1
QL
30 / 30 days
paroxetine hcl er tab er 24h 25 mg
generic
1
QL
30 / 30 days
paroxetine hcl er tab er 24h 37.5 mg
generic
1
QL
30 / 30 days
paroxetine hcl tab 10 mg
generic
1
QL
45 / 30 days
generic
1
QL
45 / 30 days
generic
1
QL
45 / 30 days
generic
1
QL
45 / 30 days
PAXIL SUSPENSION 10 MG/5ML
paroxetine hcl
BRAND
2
sertraline hcl tab 100 mg
generic
1
QL
60 / 30 days
generic
1
QL
60 / 30 days
generic
1
QL
60 / 30 days
nefazodone hcl tab 100 mg
generic
1
generic
1
generic
1
generic
1
generic
1
*Serotonin Modulators**
2
PAGE 42
PRODUCT DESCRIPTION
BRAND/GEN
TIER
OLEPTRO TAB ER 24H 150 MG
trazodone hcl
BRAND
OLEPTRO TAB ER 24H 300 MG
trazodone hcl
BRAND
2
trazodone hcl tab 100 mg
generic
1
generic
1
generic
1
generic
1
VIIBRYD KIT 10 & 20 & 40 MG
vilazodone hcl
BRAND
2
VIIBRYD TAB 10 MG
vilazodone hcl
BRAND
2
VIIBRYD TAB 20 MG
vilazodone hcl
BRAND
VIIBRYD TAB 40 MG
vilazodone hcl
BRAND
QL
30 / 30 days
ST
QL
30 / 30 days
2
ST
QL
30 / 30 days
2
ST
*Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)**
QL
desvenlafaxine er tab er 24h 100 mg
generic
30 / 30 days
1
ST
QL
desvenlafaxine er tab er 24h 50 mg
generic
30 / 30 days
1
ST
QL
duloxetine hcl cp dr part 20 mg
generic
60 / 30 days
1
PA
QL
generic
60 / 30 days
1
PA
QL
generic
60 / 30 days
1
PA
QL
PRISTIQ TAB ER 24H 100 MG
desvenlafaxine succinate
BRAND
PRISTIQ TAB ER 24H 50 MG
desvenlafaxine succinate
BRAND
venlafaxine hcl er cap er 24h 150 mg
generic
30 / 30 days
3
ST
QL
30 / 30 days
3
ST
1
QL
30 / 30 days
1
PAGE 43
PRODUCT DESCRIPTION
BRAND/GEN
venlafaxine hcl er cap er 24h 37.5 mg
generic
venlafaxine hcl er cap er 24h 75 mg
generic
venlafaxine hcl er tab er 24h 150 mg
TIER
QL
30 / 30 days
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
VENLAFAXINE HCL ER TAB ER 24H 225 MG
venlafaxine hcl
BRAND
2
QL
30 / 30 days
venlafaxine hcl er tab er 24h 37.5 mg
generic
1
QL
30 / 30 days
venlafaxine hcl er tab er 24h 75 mg
generic
1
QL
30 / 30 days
venlafaxine hcl tab 100 mg
generic
1
QL
90 / 30 days
generic
1
QL
90 / 30 days
venlafaxine hcl tab 37.5 mg
generic
1
QL
90 / 30 days
generic
1
QL
90 / 30 days
generic
1
QL
90 / 30 days
amitriptyline hcl tab 10 mg
generic
1
generic
1
generic
1
generic
1
generic
1
generic
1
amoxapine tab 100 mg
generic
1
amoxapine tab 150 mg
generic
1
amoxapine tab 25 mg
generic
1
amoxapine tab 50 mg
generic
1
clomipramine hcl cap 25 mg
generic
1
generic
1
generic
1
desipramine hcl tab 10 mg
generic
1
generic
1
generic
1
generic
1
generic
1
*Tricyclic Agents**
PAGE 44
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
1
doxepin hcl cap 10 mg
generic
1
generic
1
generic
1
generic
1
generic
1
generic
1
imipramine hcl tab 10 mg
generic
1
generic
1
generic
1
imipramine pamoate cap 100 mg
generic
1
generic
1
generic
1
generic
1
nortriptyline hcl cap 10 mg
generic
1
generic
1
generic
1
generic
1
protriptyline hcl tab 10 mg
generic
1
protriptyline hcl tab 5 mg
generic
1
trimipramine maleate cap 100 mg
generic
1
generic
1
generic
1
acarbose tab 100 mg
generic
1
acarbose tab 25 mg
generic
1
acarbose tab 50 mg
generic
1
GLYSET TAB 100 MG
miglitol
BRAND
3
GLYSET TAB 25 MG
miglitol
BRAND
3
GLYSET TAB 50 MG
BRAND
3
*ANTIDIABETICS*
*Alpha-Glucosidase Inhibitors**
PAGE 45
PRODUCT DESCRIPTION
BRAND/GEN
TIER
miglitol
*Antidiabetic - Amylin Analogs**
SYMLIN SOLUTION 600 MCG/ML
pramlintide acetate
BRAND
2
PA
SYMLINPEN 120 SOLN PEN 2700
MCG/2.7ML
pramlintide acetate
BRAND
2
PA
SYMLINPEN 60 SOLN PEN 1500 MCG/1.5ML
pramlintide acetate
BRAND
3
PA
ACTOPLUS MET XR TAB ER 24H 15-1000
MG
pioglitazone hcl-metformin hcl
BRAND
3
ACTOPLUS MET XR TAB ER 24H 30-1000
MG
pioglitazone hcl-metformin hcl
BRAND
3
glipizide-metformin hcl tab 2.5-250 mg
generic
1
glipizide-metformin hcl tab 2.5-500 mg
generic
1
glipizide-metformin hcl tab 5-500 mg
generic
1
glyburide-metformin tab 1.25-250 mg
generic
1
glyburide-metformin tab 2.5-500 mg
generic
1
glyburide-metformin tab 5-500 mg
generic
1
JANUMET TAB 50-1000 MG
sitagliptin-metformin hcl
BRAND
3
ST
JANUMET TAB 50-500 MG
BRAND
3
ST
JANUMET XR TAB ER 24H 100-1000 MG
BRAND
3
ST
BRAND
3
ST
BRAND
3
ST
JENTADUETO TAB 2.5-1000 MG
linagliptin-metformin hcl
BRAND
3
ST
pioglitazone hcl-metformin hcl tab 15-500 mg
generic
1
pioglitazone hcl-metformin hcl tab 15-850 mg
generic
1
PRANDIMET TAB 1-500 MG
repaglinide-metformin hcl
BRAND
3
*Antidiabetic Combinations**
PAGE 46
PRODUCT DESCRIPTION
BRAND/GEN
TIER
PRANDIMET TAB 2-500 MG
repaglinide-metformin hcl
BRAND
3
metformin hcl er (osm) tab er 24h 1000 mg
generic
1
metformin hcl er (osm) tab er 24h 500 mg
generic
1
metformin hcl er tab er 24h 500 mg
generic
1
metformin hcl er tab er 24h 750 mg
generic
1
metformin hcl tab 1000 mg
generic
1
generic
1
generic
1
RIOMET SOLUTION 500 MG/5ML
metformin hcl
BRAND
3
GLUCAGEN HYPOKIT RECON SOLN 1 MG
glucagon hcl (rdna)
BRAND
3
GLUCAGEN RECON SOLN 1 MG
glucagon hcl (rdna)
BRAND
3
GLUCAGON EMERGENCY KIT 1 MG
glucagon (rdna)
BRAND
2
KORLYM TAB 300 MG
mifepristone (hyperglycemia)
BRAND
4
PROGLYCEM SUSPENSION 50 MG/ML
diazoxide
BRAND
3
JANUVIA TAB 100 MG
sitagliptin phosphate
BRAND
3
ST
JANUVIA TAB 25 MG
BRAND
3
ST
JANUVIA TAB 50 MG
BRAND
3
ST
ONGLYZA TAB 2.5 MG
saxagliptin hcl
BRAND
3
ST
ONGLYZA TAB 5 MG
saxagliptin hcl
BRAND
3
ST
TRADJENTA TAB 5 MG
linagliptin
BRAND
3
ST
*Biguanides**
*Diabetic Other**
*Dipeptidyl Peptidase-4 (DPP-4) Inhibitors**
*Dopamine Receptor Agonists - Antidiabetic**
PAGE 47
PRODUCT DESCRIPTION
BRAND/GEN
CYCLOSET TAB 0.8 MG
bromocriptine mesylate (diabetes)
BRAND
TIER
3
*Incretin Mimetic Agents (GLP-1 Receptor Agonists)**
BYDUREON PEN 2 MG
exenatide
BRAND
2
ST
BYDUREON RECON SUSP 2 MG
exenatide
BRAND
3
ST
BYETTA 10 MCG PEN SOLN PEN 10
MCG/0.04ML
exenatide
BRAND
3
ST
BYETTA 5 MCG PEN SOLN PEN 5
MCG/0.02ML
exenatide
BRAND
3
ST
VICTOZA SOLN PEN 18 MG/3ML
liraglutide
BRAND
3
ST
AVANDIA TAB 2 MG
rosiglitazone maleate
BRAND
3
AVANDIA TAB 4 MG
BRAND
3
AVANDIA TAB 8 MG
BRAND
3
pioglitazone hcl tab 15 mg
generic
1
generic
1
generic
1
APIDRA SOLOSTAR SOLN PEN 100 UNIT/ML
insulin glulisine
BRAND
2
APIDRA SOLUTION 100 UNIT/ML
insulin glulisine
BRAND
2
HUMALOG KWIKPEN SOLN PEN 100
UNIT/ML
insulin lispro (human)
BRAND
2
HUMALOG MIX 50/50 KWIKPEN SUSP PEN
(50-50) 100 UNIT/ML
insulin lispro protamine & lispro (human)
BRAND
2
HUMALOG MIX 50/50 PEN SUSP PEN (50-50)
100 UNIT/ML
BRAND
2
HUMALOG MIX 50/50 SUSPENSION (50-50)
BRAND
2
*Insulin Sensitizing Agents**
*Insulin**
PAGE 48
PRODUCT DESCRIPTION
BRAND/GEN
TIER
100 UNIT/ML
HUMALOG MIX 75/25 KWIKPEN SUSP PEN
(75-25) 100 UNIT/ML
BRAND
2
HUMALOG MIX 75/25 PEN SUSP PEN (75-25)
100 UNIT/ML
BRAND
2
HUMALOG MIX 75/25 SUSPENSION (75-25)
100 UNIT/ML
BRAND
2
HUMALOG PEN SOLN PEN 100 UNIT/ML
BRAND
2
HUMALOG SOLN CART 100 UNIT/ML
BRAND
2
HUMALOG SOLUTION 100 UNIT/ML
BRAND
2
HUMULIN 70/30 KWIKPEN SUSP PEN (70-30)
100 UNIT/ML
insulin isophane & reg (human)
BRAND
2
HUMULIN 70/30 SUSPENSION (70-30) 100
UNIT/ML
BRAND
2
HUMULIN N KWIKPEN SUSP PEN 100
UNIT/ML
insulin isophane (human)
BRAND
2
HUMULIN N SUSPENSION 100 UNIT/ML
BRAND
2
HUMULIN R SOLUTION 100 UNIT/ML
insulin regular (human)
BRAND
2
HUMULIN R U-500 (CONCENTRATED)
SOLUTION 500 UNIT/ML
BRAND
2
LANTUS FOR OPTICLIK SOLN CART 100
UNIT/ML
insulin glargine
BRAND
2
LANTUS SOLOSTAR SOLN PEN 100
UNIT/ML
insulin glargine
BRAND
2
LANTUS SOLUTION 100 UNIT/ML
insulin glargine
BRAND
2
LEVEMIR FLEXPEN SOLN PEN 100 UNIT/ML
insulin detemir
BRAND
2
PAGE 49
PRODUCT DESCRIPTION
BRAND/GEN
TIER
LEVEMIR SOLUTION 100 UNIT/ML
insulin detemir
BRAND
2
NOVOLIN 70/30 RELION SUSPENSION (7030) 100 UNIT/ML
BRAND
2
NOVOLIN 70/30 SUSPENSION (70-30) 100
UNIT/ML
BRAND
2
NOVOLIN N RELION SUSPENSION 100
UNIT/ML
BRAND
2
NOVOLIN N SUSPENSION 100 UNIT/ML
BRAND
2
NOVOLIN R RELION SOLUTION 100 UNIT/ML
BRAND
2
NOVOLIN R SOLUTION 100 UNIT/ML
BRAND
2
NOVOLOG FLEXPEN SOLN PEN 100
UNIT/ML
insulin aspart
BRAND
2
NOVOLOG MIX 70/30 FLEXPEN SUSP PEN
(70-30) 100 UNIT/ML
insulin aspart protamine & aspart (human)
BRAND
2
NOVOLOG MIX 70/30 SUSPENSION (70-30)
100 UNIT/ML
insulin aspart protamine & aspart (human)
BRAND
2
NOVOLOG PENFILL SOLN CART 100
UNIT/ML
insulin aspart
BRAND
2
NOVOLOG SOLUTION 100 UNIT/ML
insulin aspart
BRAND
2
RELION 70/30 SUSPENSION (70-30) 100
UNIT/ML
BRAND
2
RELION N SUSPENSION 100 UNIT/ML
BRAND
2
RELION R SOLUTION 100 UNIT/ML
BRAND
2
nateglinide tab 120 mg
generic
1
nateglinide tab 60 mg
generic
1
*Meglitinide Analogues**
3
PAGE 50
PRODUCT DESCRIPTION
BRAND/GEN
TIER
repaglinide tab 0.5 mg
generic
repaglinide tab 1 mg
generic
3
repaglinide tab 2 mg
generic
3
*Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors**
INVOKANA TAB 100 MG
canagliflozin
BRAND
3
PA
INVOKANA TAB 300 MG
canagliflozin
BRAND
3
PA
chlorpropamide tab 250 mg
generic
1
glimepiride tab 1 mg
generic
1
generic
1
generic
1
glipizide er tab er 24h 10 mg
generic
1
glipizide er tab er 24h 2.5 mg
generic
1
glipizide er tab er 24h 5 mg
generic
1
glipizide tab 10 mg
generic
1
glipizide tab 5 mg
generic
1
glipizide xl tab er 24h 10 mg
generic
1
glipizide xl tab er 24h 2.5 mg
generic
1
glipizide xl tab er 24h 5 mg
generic
1
glyburide tab 1.25 mg
generic
1
glyburide tab 2.5 mg
generic
1
glyburide tab 5 mg
generic
1
tolazamide tab 250 mg
generic
1
tolazamide tab 500 mg
generic
1
tolbutamide tab 500 mg
generic
1
diphenatol tab 2.5-0.025 mg
generic
1
diphenoxylate-atropine liquid 2.5-0.025 mg/5ml
generic
1
diphenoxylate-atropine tab 2.5-0.025 mg
generic
1
loperamide hcl cap 2 mg
generic
1
*Sulfonylureas**
*ANTIDIARRHEALS*
*Antiperistaltic Agents**
PAGE 51
PRODUCT DESCRIPTION
BRAND/GEN
TIER
loperamide hcl tab 2 mg
generic
1
MOTOFEN TAB 1-0.025 MG
difenoxin w/ atropine
BRAND
2
CHEMET CAP 100 MG
succimer
BRAND
3
EXJADE TAB SOL 125 MG
deferasirox
BRAND
4
PA
deferasirox
BRAND
4
PA
deferasirox
BRAND
4
PA
FERRIPROX TAB 500 MG
deferiprone
BRAND
4
deferoxamine mesylate recon soln 2 gm
generic
4
PA
deferoxamine mesylate recon soln 500 mg
generic
4
PA
depade tab 50 mg
generic
1
naloxone hcl solution 0.4 mg/ml
generic
1
naltrexone hcl tab 50 mg
generic
1
VIVITROL RECON SUSP 380 MG
naltrexone
BRAND
4
PA
ALOXI SOLUTION 0.25 MG/5ML
palonosetron hcl
BRAND
4
PA
ANZEMET SOLUTION 20 MG/ML
dolasetron mesylate
BRAND
4
PA
ANZEMET TAB 100 MG
dolasetron mesylate
BRAND
4
PA
ANZEMET TAB 50 MG
dolasetron mesylate
BRAND
4
PA
granisetron hcl tab 1 mg
generic
1
ondansetron hcl solution 4 mg/2ml
generic
1
PA
*ANTIDOTES*
*Antidotes - Chelating Agents**
*Antidotes**
*Opioid Antagonists**
PA
*ANTIEMETICS*
*5-HT3 Receptor Antagonists**
PAGE 52
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
1
generic
1
PA
ondansetron hcl tab 24 mg
generic
1
QL
30 / 30 days
generic
1
QL
90 / 30 days
generic
1
QL
90 / 30 days
ondansetron hcl-dextrose solution 32 mg/50ml
generic
4
PA
ONDANSETRON HCL-DEXTROSE
SOLUTION 32 MG/50ML
ondansetron hcl and dextrose
BRAND
4
PA
ONDANSETRON HCL-NACL SOLUTION 32
MG/50ML
ondansetron hcl and sodium chloride
BRAND
4
PA
ondansetron tab disp 4 mg
generic
1
QL
90 / 30 days
ondansetron tab disp 8 mg
generic
1
QL
90 / 30 days
meclizine hcl tab 12.5 mg
generic
1
meclizine hcl tab 25 mg
generic
1
TRANSDERM-SCOP PATCH 72HR 1.5 MG
scopolamine
BRAND
2
trimethobenzamide hcl cap 300 mg
generic
1
trimethobenzamide hcl solution 100 mg/ml
generic
1
PA
CESAMET CAP 1 MG
nabilone
BRAND
4
PA
dronabinol cap 10 mg
generic
1
dronabinol cap 2.5 mg
generic
1
dronabinol cap 5 mg
generic
1
*Antiemetics - Anticholinergic**
*Antiemetics - Miscellaneous**
*Substance P/Neurokinin 1 (NK1) Receptor Antagonists**
EMEND CAP 125 MG
aprepitant
BRAND
3
MFL
1 / 30 days
EMEND CAP 40 MG
aprepitant
BRAND
3
MFL
1 / 30 days
3
MFL
PAGE 53
PRODUCT DESCRIPTION
BRAND/GEN
TIER
EMEND CAP 80 & 125 MG
aprepitant
BRAND
EMEND CAP 80 MG
aprepitant
BRAND
3
MFL
EMEND RECON SOLN 115 MG
fosaprepitant dimeglumine
BRAND
2
PA
EMEND RECON SOLN 150 MG
fosaprepitant dimeglumine
BRAND
2
PA
1 / 30 days
1 / 30 days
*ANTIFUNGALS*
*Antifungal - Glucan Synthesis Inhibitors (Echinocandins)**
CANCIDAS RECON SOLN 50 MG
caspofungin acetate
BRAND
4
PA
CANCIDAS RECON SOLN 70 MG
caspofungin acetate
BRAND
4
PA
ABELCET SUSPENSION 5 MG/ML
amphotericin b lipid
BRAND
3
PA
AMBISOME RECON SUSP 50 MG
amphotericin b liposome
BRAND
3
PA
AMPHOTEC RECON SUSP 100 MG
amphotericin b cholesteryl sulfate complex
BRAND
2
PA
AMPHOTEC RECON SUSP 50 MG
amphotericin b cholesteryl sulfate complex
BRAND
2
PA
amphotericin b recon soln 50 mg
generic
1
PA
AMPHOTERICIN B RECON SOLN 50 MG
amphotericin b
BRAND
2
PA
GRIFULVIN V TAB 500 MG
griseofulvin microsize
BRAND
2
griseofulvin microsize suspension 125 mg/5ml
generic
1
griseofulvin microsize tab 500 mg
generic
1
griseofulvin ultramicrosize tab 125 mg
generic
1
griseofulvin ultramicrosize tab 250 mg
generic
1
nystatin tab 500000 unit
generic
1
terbinafine hcl tab 250 mg
generic
1
generic
4
*Antifungals**
*Imidazole-Related Antifungals**
fluconazole in dextrose 200 mg/100ml
PA
4
PAGE 54
PRODUCT DESCRIPTION
BRAND/GEN
TIER
fluconazole in dextrose 400 mg/200ml
generic
fluconazole in dextrose solution 200 mg/100ml
generic
4
PA
fluconazole in dextrose solution 400 mg/200ml
generic
4
PA
fluconazole in sodium chloride solution 100-0.9
mg/50ml-%
generic
4
PA
mg/100ml-%
generic
4
PA
mg/200ml-%
generic
4
PA
fluconazole recon susp 10 mg/ml
generic
1
fluconazole recon susp 40 mg/ml
generic
1
fluconazole tab 100 mg
generic
1
generic
1
generic
1
generic
1
itraconazole cap 100 mg
generic
1
ketoconazole tab 200 mg
generic
1
NOXAFIL SOLUTION 300 MG/16.7ML
posaconazole
BRAND
2
NOXAFIL TAB DR 100 MG
posaconazole
BRAND
2
SPORANOX SOLUTION 10 MG/ML
itraconazole
BRAND
3
PA
voriconazole recon soln 200 mg
generic
1
PA
voriconazole recon susp 40 mg/ml
generic
1
voriconazole tab 200 mg
generic
1
voriconazole tab 50 mg
generic
1
arbinoxa solution 4 mg/5ml
generic
1
arbinoxa tab 4 mg
generic
1
clemastine fumarate tab 2.68 mg
generic
1
diphenhydramine hcl cap 50 mg
generic
1
diphenhydramine hcl solution 50 mg/ml
generic
1
PA
PA
PA
*ANTIHISTAMINES*
*Antihistamines - Ethanolamines**
PAGE 55
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Antihistamines - Non-Sedating**
CLARINEX SYRUP 0.5 MG/ML
desloratadine
BRAND
3
desloratadine tab 5 mg
generic
1
desloratadine tab disp 2.5 mg
generic
1
desloratadine tab disp 5 mg
generic
1
levocetirizine dihydrochloride solution 2.5
mg/5ml
generic
1
levocetirizine dihydrochloride tab 5 mg
generic
1
phenadoz suppos 12.5 mg
generic
1
phenadoz suppos 25 mg
generic
1
promethazine hcl 12.5 mg
generic
1
promethazine hcl 50 mg
generic
1
promethazine hcl solution 25 mg/ml
generic
1
PA
promethazine hcl solution 50 mg/ml
generic
1
PA
promethazine hcl solution 6.25 mg/5ml
generic
1
promethazine hcl suppos 12.5 mg
generic
1
promethazine hcl suppos 25 mg
generic
1
promethazine hcl syrup 6.25 mg/5ml
generic
1
promethazine hcl tab 12.5 mg
generic
1
promethazine hcl tab 25 mg
generic
1
promethazine hcl tab 50 mg
generic
1
promethegan suppos 12.5 mg
generic
1
promethegan suppos 25 mg
generic
1
promethegan suppos 50 mg
generic
2
cyproheptadine hcl syrup 2 mg/5ml
generic
1
cyproheptadine hcl tab 4 mg
generic
1
QL
30 / 30 days
*Antihistamines - Phenothiazines**
*Antihistamines - Piperidines**
*ANTIHYPERLIPIDEMICS*
*Antihyperlipidemics - Combinations**
PAGE 56
PRODUCT DESCRIPTION
BRAND/GEN
TIER
VYTORIN TAB 10-10 MG
ezetimibe-simvastatin
BRAND
2
ST
BRAND
2
ST
BRAND
2
ST
BRAND
2
ST
KYNAMRO SOLN PRSYR 200 MG/ML
mipomersen sodium
BRAND
4
PA
omega-3-acid ethyl esters cap 1 gm
generic
1
cholestyramine light packet 4 gm
generic
3
cholestyramine light powder 4 gm/dose
generic
3
cholestyramine packet 4 gm
generic
1
colestipol hcl granules 5 gm
generic
1
colestipol hcl packet 5 gm
generic
1
colestipol hcl tab 1 gm
generic
1
micronized colestipol hcl tab 1 gm
generic
1
prevalite packet 4 gm
generic
3
prevalite powder 4 gm/dose
generic
3
WELCHOL PACKET 3.75 GM
colesevelam hcl
BRAND
3
WELCHOL TAB 625 MG
colesevelam hcl
BRAND
3
fenofibrate micronized cap 130 mg
generic
1
generic
1
generic
1
generic
1
generic
1
fenofibrate tab 145 mg
generic
1
generic
1
generic
1
*Antihyperlipidemics - Misc.**
*Bile Acid Sequestrants**
*Fibric Acid Derivatives**
PAGE 57
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
1
fenofibric acid cap dr 135 mg
generic
1
fenofibric acid cap dr 45 mg
generic
1
fenofibric acid tab 105 mg
generic
1
fenofibric acid tab 35 mg
generic
1
gemfibrozil tab 600 mg
generic
1
ADVICOR TAB ER 24H 1000-20 MG
niacin-lovastatin
BRAND
3
niacin-lovastatin
BRAND
3
niacin-lovastatin
BRAND
3
niacin-lovastatin
BRAND
3
atorvastatin calcium tab 10 mg
generic
1
generic
1
generic
1
generic
1
CRESTOR TAB 10 MG
rosuvastatin calcium
BRAND
3
ST
CRESTOR TAB 20 MG
BRAND
3
ST
CRESTOR TAB 40 MG
BRAND
3
ST
CRESTOR TAB 5 MG
BRAND
3
ST
fluvastatin sodium cap 20 mg
generic
1
fluvastatin sodium cap 40 mg
generic
1
LESCOL XL TAB ER 24H 80 MG
fluvastatin sodium
BRAND
2
LIVALO TAB 1 MG
pitavastatin calcium
BRAND
3
ST
LIVALO TAB 2 MG
BRAND
3
ST
LIVALO TAB 4 MG
BRAND
3
ST
*HMG CoA Reductase Inhibitors**
PAGE 58
PRODUCT DESCRIPTION
BRAND/GEN
TIER
lovastatin tab 10 mg
generic
1
generic
1
generic
1
pravastatin sodium tab 10 mg
generic
1
generic
1
generic
1
generic
1
SIMCOR TAB ER 24H 1000-20 MG
niacin-simvastatin
BRAND
2
niacin-simvastatin
BRAND
2
niacin-simvastatin
BRAND
2
niacin-simvastatin
BRAND
2
niacin-simvastatin
BRAND
2
simvastatin 10 mg
generic
1
simvastatin 20 mg
generic
1
simvastatin 40 mg
generic
1
simvastatin 5 mg
generic
1
simvastatin 80 mg
generic
1
simvastatin tab 10 mg
generic
1
generic
1
generic
1
generic
1
generic
1
BRAND
2
*Intestinal Cholesterol Absorption Inhibitors**
ZETIA TAB 10 MG
ezetimibe
ST
*Microsomal Triglyceride Transfer Protein (MTP) Inhibitors**
JUXTAPID CAP 10 MG
lomitapide mesylate
BRAND
4
JUXTAPID CAP 20 MG
lomitapide mesylate
BRAND
4
4
PAGE 59
PRODUCT DESCRIPTION
BRAND/GEN
JUXTAPID CAP 5 MG
lomitapide mesylate
BRAND
TIER
*Nicotinic Acid Derivatives**
niacin er (antihyperlipidemic) tab er 1000 mg
generic
1
generic
1
generic
1
benazepril hcl tab 10 mg
generic
1
generic
1
generic
1
generic
1
captopril tab 100 mg
generic
1
captopril tab 12.5 mg
generic
1
captopril tab 25 mg
generic
1
captopril tab 50 mg
generic
1
enalapril maleate 10 mg
generic
1
enalapril maleate 5 mg
generic
1
enalapril maleate tab 10 mg
generic
1
enalapril maleate tab 2.5 mg
generic
1
generic
1
generic
1
fosinopril sodium 10 mg
generic
1
generic
1
generic
1
fosinopril sodium tab 10 mg
generic
1
generic
1
generic
1
lisinopril 2.5 mg
generic
1
lisinopril 20 mg
generic
1
lisinopril 40 mg
generic
1
lisinopril 5 mg
generic
1
*ANTIHYPERTENSIVES*
*ACE Inhibitors**
1
PAGE 60
PRODUCT DESCRIPTION
BRAND/GEN
TIER
lisinopril tab 10 mg
generic
lisinopril tab 2.5 mg
generic
1
generic
1
generic
1
generic
1
lisinopril tab 5 mg
generic
1
moexipril hcl tab 15 mg
generic
1
moexipril hcl tab 7.5 mg
generic
1
perindopril erbumine tab 2 mg
generic
1
generic
1
generic
1
quinapril hcl tab 10 mg
generic
1
generic
1
generic
1
generic
1
ramipril cap 1.25 mg
generic
1
ramipril cap 10 mg
generic
1
ramipril cap 2.5 mg
generic
1
ramipril cap 5 mg
generic
1
trandolapril tab 1 mg
generic
1
generic
1
generic
1
BRAND
3
BENICAR TAB 20 MG
olmesartan medoxomil
BRAND
3
ST
BENICAR TAB 40 MG
BRAND
3
ST
BENICAR TAB 5 MG
BRAND
3
ST
candesartan cilexetil tab 16 mg
generic
1
generic
1
*Agents for Pheochromocytoma**
DIBENZYLINE CAP 10 MG
phenoxybenzamine hcl
*Angiotensin II Receptor Antagonists**
PAGE 61
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
1
generic
1
EDARBI TAB 40 MG
azilsartan medoxomil
BRAND
2
ST
EDARBI TAB 80 MG
azilsartan medoxomil
BRAND
2
ST
irbesartan tab 150 mg
generic
1
generic
1
generic
1
losartan potassium tab 100 mg
generic
1
generic
1
generic
1
telmisartan tab 20 mg
generic
1
generic
1
generic
1
TEVETEN TAB 400 MG
eprosartan mesylate
BRAND
2
clonidine hcl patch wk 0.1 mg/24hr
generic
1
ST
generic
1
ST
generic
1
ST
clonidine hcl tab 0.1 mg
generic
1
generic
1
generic
1
doxazosin mesylate tab 1 mg
generic
1
generic
1
generic
1
generic
1
guanfacine hcl tab 1 mg
generic
1
guanfacine hcl tab 2 mg
generic
1
methyldopa tab 250 mg
generic
1
methyldopa tab 500 mg
generic
1
prazosin hcl cap 1 mg
generic
1
*Antiadrenergic Antihypertensives**
PAGE 62
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
1
generic
1
terazosin hcl cap 1 mg
generic
1
generic
1
generic
1
generic
1
amlodipine besy-benazepril hcl cap 10-20 mg
generic
1
generic
1
amlodipine besy-benazepril hcl cap 2.5-10 mg
generic
1
generic
1
generic
1
generic
1
atenolol-chlorthalidone tab 100-25 mg
generic
1
atenolol-chlorthalidone tab 50-25 mg
generic
1
benazepril-hydrochlorothiazide tab 10-12.5 mg
generic
1
generic
1
benazepril-hydrochlorothiazide tab 20-25 mg
generic
1
generic
1
BENICAR HCT TAB 20-12.5 MG
olmesartan medoxomil-hydrochlorothiazide
BRAND
3
ST
BENICAR HCT TAB 40-12.5 MG
BRAND
3
ST
BENICAR HCT TAB 40-25 MG
BRAND
3
ST
bisoprolol-hydrochlorothiazide tab 10-6.25 mg
generic
1
bisoprolol-hydrochlorothiazide tab 2.5-6.25 mg
generic
1
bisoprolol-hydrochlorothiazide tab 5-6.25 mg
generic
1
candesartan cilexetil-hctz tab 16-12.5 mg
generic
1
candesartan cilexetil-hctz tab 32-12.5 mg
generic
1
candesartan cilexetil-hctz tab 32-25 mg
generic
1
captopril-hydrochlorothiazide tab 25-15 mg
generic
1
generic
1
*Antihypertensive Combinations**
1
PAGE 63
PRODUCT DESCRIPTION
BRAND/GEN
generic
generic
1
DUTOPROL TAB ER 24H 100-12.5 MG
metoprolol & hydrochlorothiazide
BRAND
3
BRAND
3
BRAND
3
enalapril-hydrochlorothiazide tab 10-25 mg
generic
1
enalapril-hydrochlorothiazide tab 5-12.5 mg
generic
1
fosinopril sodium-hctz tab 10-12.5 mg
generic
1
fosinopril sodium-hctz tab 20-12.5 mg
generic
1
irbesartan-hydrochlorothiazide tab 150-12.5 mg
generic
1
irbesartan-hydrochlorothiazide tab 300-12.5 mg
generic
1
lisinopril-hydrochlorothiazide 10-12.5 mg
generic
1
lisinopril-hydrochlorothiazide 20-12.5 mg
generic
1
lisinopril-hydrochlorothiazide 20-25 mg
generic
1
lisinopril-hydrochlorothiazide tab 10-12.5 mg
generic
1
lisinopril-hydrochlorothiazide tab 20-12.5 mg
generic
1
lisinopril-hydrochlorothiazide tab 20-25 mg
generic
1
losartan potassium-hctz tab 100-12.5 mg
generic
1
losartan potassium-hctz tab 100-25 mg
generic
1
losartan potassium-hctz tab 50-12.5 mg
generic
1
methyldopa-hydrochlorothiazide tab 250-15 mg
generic
1
methyldopa-hydrochlorothiazide tab 250-25 mg
generic
1
metoprolol-hydrochlorothiazide tab 100-25 mg
generic
1
generic
1
generic
1
moexipril-hydrochlorothiazide tab 15-12.5 mg
generic
1
moexipril-hydrochlorothiazide tab 15-25 mg
generic
1
moexipril-hydrochlorothiazide tab 7.5-12.5 mg
generic
1
propranolol-hctz tab 40-25 mg
generic
1
propranolol-hctz tab 80-25 mg
generic
1
quinapril-hydrochlorothiazide tab 10-12.5 mg
generic
1
PAGE 64
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
quinapril-hydrochlorothiazide tab 20-12.5 mg
generic
1
quinapril-hydrochlorothiazide tab 20-25 mg
generic
1
TEKTURNA HCT TAB 150-12.5 MG
aliskiren-hydrochlorothiazide
BRAND
2
ST
TEKTURNA HCT TAB 150-25 MG
BRAND
2
ST
TEKTURNA HCT TAB 300-12.5 MG
BRAND
2
ST
TEKTURNA HCT TAB 300-25 MG
BRAND
2
ST
telmisartan-amlodipine tab 40-10 mg
generic
1
generic
1
generic
1
generic
1
telmisartan-hctz tab 40-12.5 mg
generic
1
telmisartan-hctz tab 80-12.5 mg
generic
3
telmisartan-hctz tab 80-25 mg
generic
1
valsartan-hydrochlorothiazide tab 160-12.5 mg
generic
1
valsartan-hydrochlorothiazide tab 160-25 mg
generic
1
generic
1
valsartan-hydrochlorothiazide tab 320-25 mg
generic
1
generic
1
TEKTURNA TAB 150 MG
aliskiren fumarate
BRAND
2
ST
TEKTURNA TAB 300 MG
aliskiren fumarate
BRAND
2
ST
*Direct Renin Inhibitors**
*Selective Aldosterone Receptor Antagonists (SARAs)**
eplerenone tab 25 mg
generic
1
eplerenone tab 50 mg
generic
1
hydralazine hcl tab 10 mg
generic
1
generic
1
generic
1
*Vasodilators**
1
PAGE 65
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
minoxidil tab 10 mg
generic
1
minoxidil tab 2.5 mg
generic
1
atovaquone-proguanil hcl tab 250-100 mg
generic
1
atovaquone-proguanil hcl tab 62.5-25 mg
generic
1
COARTEM TAB 20-120 MG
artemether-lumefantrine
BRAND
3
chloroquine phosphate tab 250 mg
generic
1
chloroquine phosphate tab 500 mg
generic
1
DARAPRIM TAB 25 MG
pyrimethamine
BRAND
3
hydroxychloroquine sulfate tab 200 mg
generic
1
mefloquine hcl tab 250 mg
generic
1
primaquine phosphate tab 26.3 mg
generic
1
quinine sulfate cap 324 mg
generic
1
MESTINON SYRUP 60 MG/5ML
pyridostigmine bromide
BRAND
3
MESTINON TAB ER 180 MG
BRAND
3
pyridostigmine bromide tab 60 mg
generic
1
REGONOL SOLUTION 5 MG/ML
BRAND
4
generic
3
CYCLOSERINE CAP 250 MG
cycloserine
BRAND
2
ethambutol hcl tab 100 mg
generic
1
*ANTIMALARIALS*
*Antimalarial Combinations**
*Antimalarials**
*ANTIMYASTHENIC/CHOLINERGIC AGENTS*
*Antimyasthenic/Cholinergic Agents**
PA
*ANTIMYCOBACTERIAL AGENTS*
*Anti TB Combinations**
isonarif cap 150-300 mg
*Antimycobacterial Agents**
PAGE 66
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ethambutol hcl tab 400 mg
generic
1
isoniazid solution 100 mg/ml
generic
1
ISONIAZID SYRUP 50 MG/5ML
isoniazid
BRAND
2
isoniazid tab 100 mg
generic
1
isoniazid tab 300 mg
generic
1
PASER PACKET 4 GM
aminosalicylic acid
BRAND
2
pyrazinamide tab 500 mg
generic
1
rifabutin cap 150 mg
generic
3
rifampin cap 150 mg
generic
1
rifampin cap 300 mg
generic
1
rifampin recon soln 600 mg
generic
1
PA
PA
*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*
*Alkylating Agents**
ALKERAN TAB 2 MG
melphalan
BRAND
3
BICNU RECON SOLN 100 MG
carmustine
BRAND
4
PA
carboplatin recon soln 150 mg
generic
4
PA
generic
4
PA
generic
4
PA
carboplatin solution 150 mg/15ml
generic
4
PA
generic
4
PA
generic
4
PA
generic
4
PA
cisplatin solution 100 mg/100ml
generic
4
PA
generic
4
PA
generic
4
PA
cyclophosphamide cap 25 mg
generic
1
PA
cyclophosphamide cap 50 mg
generic
1
PA
PAGE 67
PRODUCT DESCRIPTION
BRAND/GEN
CYCLOPHOSPHAMIDE RECON SOLN 1 GM
cyclophosphamide
BRAND
4
PA
CYCLOPHOSPHAMIDE RECON SOLN 2 GM
cyclophosphamide
BRAND
4
PA
CYCLOPHOSPHAMIDE RECON SOLN 500
MG
cyclophosphamide
BRAND
4
PA
cyclophosphamide tab 25 mg
generic
4
PA
cyclophosphamide tab 50 mg
generic
4
PA
ELOXATIN SOLUTION 200 MG/40ML
oxaliplatin
BRAND
4
PA
GLIADEL WAFER WAFER 7.7 MG
carmustine in polifeprosan
BRAND
4
PA
HEXALEN CAP 50 MG
altretamine
BRAND
4
PA
IFEX RECON SOLN 3 GM
ifosfamide
BRAND
4
PA
ifosfamide recon soln 1 gm
generic
4
PA
IFOSFAMIDE RECON SOLN 3 GM
ifosfamide
BRAND
4
PA
ifosfamide solution 1 gm/20ml
generic
4
PA
ifosfamide solution 3 gm/60ml
generic
4
PA
lomustine cap 10 mg
generic
4
PA
lomustine cap 100 mg
generic
4
PA
lomustine cap 40 mg
generic
4
PA
melphalan hcl recon soln 50 mg
generic
1
PA
MUSTARGEN RECON SOLN 10 MG
mechlorethamine hcl
BRAND
4
PA
MYLERAN TAB 2 MG
busulfan
BRAND
4
PA
oxaliplatin recon soln 100 mg
generic
4
PA
oxaliplatin recon soln 50 mg
generic
4
PA
oxaliplatin solution 100 mg/20ml
generic
4
PA
oxaliplatin solution 50 mg/10ml
generic
4
PA
PAGE 68
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
temozolomide cap 100 mg
generic
4
PA
generic
4
PA
generic
4
PA
generic
4
PA
generic
4
PA
generic
4
PA
thiotepa recon soln 15 mg
generic
4
PA
TREANDA RECON SOLN 100 MG
bendamustine hcl
BRAND
4
PA
TREANDA RECON SOLN 25 MG
bendamustine hcl
BRAND
4
PA
ZANOSAR RECON SOLN 1 GM
streptozocin
BRAND
4
PA
ALIMTA RECON SOLN 100 MG
pemetrexed disodium
BRAND
4
PA
ALIMTA RECON SOLN 500 MG
pemetrexed disodium
BRAND
4
PA
ARRANON SOLUTION 5 MG/ML
nelarabine
BRAND
4
PA
azacitidine recon susp 100 mg
generic
4
PA
capecitabine tab 150 mg
generic
4
PA
capecitabine tab 500 mg
generic
4
PA
cladribine solution 1 mg/ml
generic
4
PA
CLOLAR SOLUTION 1 MG/ML
clofarabine
BRAND
4
PA
cytarabine (pf) solution 20 mg/ml
generic
4
PA
cytarabine recon soln 1 gm
generic
4
PA
cytarabine recon soln 100 mg
generic
4
PA
cytarabine recon soln 2 gm
generic
4
PA
cytarabine recon soln 500 mg
generic
4
PA
cytarabine solution 20 mg/ml
generic
4
PA
*Antimetabolites**
PAGE 69
PRODUCT DESCRIPTION
BRAND/GEN
decitabine recon soln 50 mg
generic
4
PA
DEPOCYT SUSPENSION 50 MG/5ML
cytarabine liposome
BRAND
4
PA
floxuridine recon soln 0.5 gm
generic
4
PA
fluorouracil solution 1 gm/20ml
generic
4
PA
fluorouracil solution 2.5 gm/50ml
generic
4
PA
fluorouracil solution 5 gm/100ml
generic
4
PA
fluorouracil solution 500 mg/10ml
generic
4
PA
FOLOTYN SOLUTION 20 MG/ML
pralatrexate
BRAND
4
PA
FOLOTYN SOLUTION 40 MG/2ML
pralatrexate
BRAND
4
PA
gemcitabine hcl recon soln 1 gm
generic
4
PA
gemcitabine hcl recon soln 2 gm
generic
4
PA
gemcitabine hcl recon soln 200 mg
generic
4
PA
GEMCITABINE HCL SOLUTION 1 GM/26.3ML
gemcitabine hcl
BRAND
4
PA
GEMCITABINE HCL SOLUTION 2 GM/52.6ML
gemcitabine hcl
BRAND
4
PA
GEMCITABINE HCL SOLUTION 200
MG/5.26ML
gemcitabine hcl
BRAND
4
PA
mercaptopurine tab 50 mg
generic
1
methotrexate sodium (pf) solution 1 gm/40ml
generic
1
PA
methotrexate sodium (pf) solution 100 mg/4ml
generic
1
PA
generic
1
PA
methotrexate sodium (pf) solution 25 mg/ml
generic
1
PA
generic
1
PA
generic
1
PA
methotrexate sodium recon soln 1 gm
generic
1
PA
methotrexate sodium solution 25 mg/ml
generic
1
PA
methotrexate tab 2.5 mg
generic
1
PAGE 70
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
OFORTA TAB 10 MG
fludarabine phosphate
BRAND
4
TREXALL TAB 10 MG
methotrexate sodium
BRAND
2
TREXALL TAB 15 MG
methotrexate sodium
BRAND
2
TREXALL TAB 5 MG
methotrexate sodium
BRAND
2
TREXALL TAB 7.5 MG
methotrexate sodium
BRAND
2
AVASTIN SOLUTION 100 MG/4ML
bevacizumab
BRAND
4
PA
AVASTIN SOLUTION 400 MG/16ML
bevacizumab
BRAND
4
PA
CYRAMZA SOLUTION 100 MG/10ML
ramucirumab
BRAND
4
CYRAMZA SOLUTION 500 MG/50ML
ramucirumab
BRAND
4
ADCETRIS RECON SOLN 50 MG
brentuximab vedotin
BRAND
4
PA
ARZERRA CONC 100 MG/5ML
ofatumumab
BRAND
4
PA
BEXXAR CONC 14 MG/ML
tositumomab
BRAND
4
PA
CAMPATH SOLUTION 30 MG/ML
alemtuzumab
BRAND
4
PA
ERBITUX SOLUTION 100 MG/50ML
cetuximab
BRAND
4
PA
ERBITUX SOLUTION 200 MG/100ML
cetuximab
BRAND
4
PA
HERCEPTIN RECON SOLN 440 MG
trastuzumab
BRAND
4
PA
PERJETA SOLUTION 420 MG/14ML
pertuzumab
BRAND
4
PA
RITUXAN CONC 10 MG/ML
rituximab
BRAND
4
PA
VECTIBIX SOLUTION 100 MG/5ML
panitumumab
BRAND
4
PA
PA
*Antineoplastic - Angiogenesis Inhibitors**
*Antineoplastic - Antibodies**
PAGE 71
PRODUCT DESCRIPTION
BRAND/GEN
TIER
VECTIBIX SOLUTION 400 MG/20ML
panitumumab
BRAND
4
anastrozole tab 1 mg
generic
3
bicalutamide tab 50 mg
generic
1
ELIGARD KIT 22.5 MG
leuprolide acetate (3 month)
BRAND
4
PA
ELIGARD KIT 30 MG
BRAND
4
PA
ELIGARD KIT 45 MG
BRAND
4
PA
ELIGARD KIT 7.5 MG
leuprolide acetate
BRAND
4
PA
EMCYT CAP 140 MG
estramustine phosphate sodium
BRAND
4
PA
exemestane tab 25 mg
generic
1
FASLODEX SOLUTION 250 MG/5ML
fulvestrant
BRAND
4
PA
flutamide cap 125 mg
generic
1
PA
letrozole tab 2.5 mg
generic
1
leuprolide acetate kit 1 mg/0.2ml
generic
4
PA
LUPRON DEPOT KIT 11.25 MG
BRAND
4
PA
BRAND
4
PA
leuprolide acetate
BRAND
4
PA
LUPRON DEPOT KIT 30 MG
BRAND
4
PA
LUPRON DEPOT KIT 45 MG
BRAND
4
PA
leuprolide acetate
BRAND
4
PA
LYSODREN TAB 500 MG
mitotane
BRAND
4
PA
megestrol acetate suspension 40 mg/ml
generic
4
megestrol acetate suspension 400 mg/10ml
generic
4
PA
*Antineoplastic - Hormonal and Related Agents**
4
PAGE 72
PRODUCT DESCRIPTION
BRAND/GEN
TIER
megestrol acetate suspension 800 mg/20ml
generic
megestrol acetate tab 20 mg
generic
4
megestrol acetate tab 40 mg
generic
4
NILANDRON TAB 150 MG
nilutamide
BRAND
4
QL
60 / 30 days
PA
SOLTAMOX SOLUTION 10 MG/5ML
tamoxifen citrate
BRAND
0
GL
Female
AL
40 to 999 yrs old
tamoxifen citrate tab 10 mg
generic
0
tamoxifen citrate tab 20 mg
generic
0
TRELSTAR DEPOT MIXJECT RECON SUSP
3.75 MG
triptorelin pamoate
BRAND
4
PA
TRELSTAR DEPOT RECON SUSP 3.75 MG
triptorelin pamoate
BRAND
4
PA
TRELSTAR LA MIXJECT RECON SUSP 11.25
MG
triptorelin pamoate
BRAND
4
PA
TRELSTAR LA RECON SUSP 11.25 MG
triptorelin pamoate
BRAND
4
PA
TRELSTAR MIXJECT RECON SUSP 22.5 MG
triptorelin pamoate
BRAND
4
PA
VANTAS KIT 50 MG
histrelin acetate
BRAND
4
PA
XTANDI CAP 40 MG
enzalutamide
BRAND
4
PA
ZOLADEX IMPLANT 10.8 MG
goserelin acetate
BRAND
4
PA
ZOLADEX IMPLANT 3.6 MG
goserelin acetate
BRAND
4
PA
ZYTIGA TAB 250 MG
abiraterone acetate
BRAND
4
PA
POMALYST CAP 1 MG
pomalidomide
BRAND
4
PA
POMALYST CAP 2 MG
pomalidomide
BRAND
4
PA
POMALYST CAP 3 MG
pomalidomide
BRAND
4
PA
*Antineoplastic - Immunomodulators**
PAGE 73
PRODUCT DESCRIPTION
BRAND/GEN
TIER
POMALYST CAP 4 MG
pomalidomide
BRAND
4
PA
adriamycin recon soln 10 mg
generic
4
PA
ADRIAMYCIN RECON SOLN 20 MG
doxorubicin hcl
BRAND
4
PA
adriamycin recon soln 50 mg
generic
4
PA
adriamycin solution 2 mg/ml
generic
4
PA
COSMEGEN RECON SOLN 0.5 MG
dactinomycin
BRAND
4
PA
dactinomycin recon soln 0.5 mg
generic
4
PA
daunorubicin hcl injectable 5 mg/ml
generic
4
PA
daunorubicin hcl recon soln 20 mg
generic
4
PA
DAUNOXOME INJECTABLE 2 MG/ML
daunorubicin citrate liposome
BRAND
4
PA
DOXIL INJECTABLE 2 MG/ML
doxorubicin hcl liposomal
BRAND
4
PA
doxorubicin hcl liposomal injectable 2 mg/ml
generic
4
PA
doxorubicin hcl recon soln 10 mg
generic
4
PA
doxorubicin hcl recon soln 50 mg
generic
4
PA
doxorubicin hcl solution 2 mg/ml
generic
4
PA
EPIRUBICIN HCL RECON SOLN 200 MG
epirubicin hcl
BRAND
4
PA
EPIRUBICIN HCL RECON SOLN 50 MG
epirubicin hcl
BRAND
4
PA
epirubicin hcl solution 200 mg/100ml
generic
4
PA
epirubicin hcl solution 50 mg/25ml
generic
4
PA
idarubicin hcl solution 10 mg/10ml
generic
4
PA
generic
4
PA
generic
4
PA
lipodox 50 injectable 2 mg/ml
generic
4
PA
lipodox injectable 2 mg/ml
generic
4
PA
*Antineoplastic Antibiotics**
PAGE 74
PRODUCT DESCRIPTION
BRAND/GEN
TIER
VALSTAR SOLUTION 40 MG/ML
valrubicin
BRAND
4
PA
AFINITOR DISPERZ TAB SOL 2 MG
everolimus
BRAND
4
PA
everolimus
BRAND
4
PA
everolimus
BRAND
4
PA
AFINITOR TAB 10 MG
everolimus
BRAND
4
PA
AFINITOR TAB 2.5 MG
everolimus
BRAND
4
PA
AFINITOR TAB 5 MG
everolimus
BRAND
4
PA
AFINITOR TAB 7.5 MG
everolimus
BRAND
4
PA
BOSULIF TAB 100 MG
bosutinib
BRAND
4
PA
BOSULIF TAB 500 MG
bosutinib
BRAND
4
PA
GILOTRIF TAB 20 MG
afatinib dimaleate
BRAND
4
GILOTRIF TAB 30 MG
afatinib dimaleate
BRAND
4
GILOTRIF TAB 40 MG
afatinib dimaleate
BRAND
4
GLEEVEC TAB 100 MG
imatinib mesylate
BRAND
4
PA
GLEEVEC TAB 400 MG
imatinib mesylate
BRAND
4
PA
ICLUSIG TAB 15 MG
ponatinib hcl
BRAND
4
ICLUSIG TAB 45 MG
ponatinib hcl
BRAND
4
IMBRUVICA CAP 140 MG
ibrutinib
BRAND
4
INLYTA TAB 1 MG
axitinib
BRAND
4
PA
INLYTA TAB 5 MG
BRAND
4
PA
*Antineoplastic Enzyme Inhibitors**
PAGE 75
PRODUCT DESCRIPTION
BRAND/GEN
TIER
axitinib
IRESSA TAB 250 MG
gefitinib
BRAND
4
ISTODAX RECON SOLN 10 MG
romidepsin
BRAND
4
PA
JAKAFI TAB 10 MG
ruxolitinib phosphate
BRAND
4
PA
JAKAFI TAB 15 MG
BRAND
4
PA
JAKAFI TAB 20 MG
BRAND
4
PA
JAKAFI TAB 25 MG
BRAND
4
PA
JAKAFI TAB 5 MG
BRAND
4
PA
KYPROLIS RECON SOLN 60 MG
carfilzomib
BRAND
4
PA
MEKINIST TAB 0.5 MG
trametinib dimethyl sulfoxide
BRAND
4
MEKINIST TAB 2 MG
trametinib dimethyl sulfoxide
BRAND
4
NEXAVAR TAB 200 MG
sorafenib tosylate
BRAND
4
PA
SPRYCEL TAB 100 MG
dasatinib
BRAND
4
PA
SPRYCEL TAB 140 MG
dasatinib
BRAND
4
PA
SPRYCEL TAB 20 MG
dasatinib
BRAND
4
PA
SPRYCEL TAB 50 MG
dasatinib
BRAND
4
PA
SPRYCEL TAB 70 MG
dasatinib
BRAND
4
PA
SPRYCEL TAB 80 MG
dasatinib
BRAND
4
PA
SUTENT CAP 12.5 MG
sunitinib malate
BRAND
4
PA
SUTENT CAP 25 MG
sunitinib malate
BRAND
4
PA
SUTENT CAP 50 MG
BRAND
4
PA
PAGE 76
PRODUCT DESCRIPTION
BRAND/GEN
TIER
sunitinib malate
TAFINLAR CAP 50 MG
dabrafenib mesylate
BRAND
4
PA
TAFINLAR CAP 75 MG
dabrafenib mesylate
BRAND
4
PA
TARCEVA TAB 100 MG
erlotinib hcl
BRAND
4
PA
TARCEVA TAB 150 MG
erlotinib hcl
BRAND
4
PA
TARCEVA TAB 25 MG
erlotinib hcl
BRAND
4
PA
TASIGNA CAP 150 MG
nilotinib hcl
BRAND
4
PA
TASIGNA CAP 200 MG
nilotinib hcl
BRAND
4
PA
TORISEL SOLUTION 25 MG/ML
temsirolimus
BRAND
4
PA
TYKERB TAB 250 MG
lapatinib ditosylate
BRAND
4
PA
VELCADE RECON SOLN 3.5 MG
bortezomib
BRAND
4
PA
VOTRIENT TAB 200 MG
pazopanib hcl
BRAND
4
PA
ZELBORAF TAB 240 MG
vemurafenib
BRAND
4
PA
ZOLINZA CAP 100 MG
vorinostat
BRAND
4
PA
ZYKADIA CAP 150 MG
ceritinib
BRAND
4
ELSPAR RECON SOLN 10000 UNIT
asparaginase
BRAND
2
ERWINAZE RECON SOLN 10000 UNIT
asparaginase erwinia chrysanthemi
BRAND
4
ONCASPAR SOLUTION 750 UNIT/ML
pegaspargase
BRAND
2
BRAND
4
*Antineoplastic Enzymes**
*Antineoplastics Misc.**
ALFERON N SOLUTION 5000000 UNIT/ML
interferon alfa-n3
PA
4
PAGE 77
PRODUCT DESCRIPTION
BRAND/GEN
dacarbazine powder
generic
dacarbazine recon soln 100 mg
generic
4
PA
dacarbazine recon soln 200 mg
generic
4
PA
hydroxyurea cap 500 mg
generic
4
MATULANE CAP 50 MG
procarbazine hcl
BRAND
4
NIPENT RECON SOLN 10 MG
pentostatin
BRAND
4
ONTAK SOLUTION 150 MCG/ML
denileukin diftitox
BRAND
4
PA
pentostatin recon soln 10 mg
generic
4
PA
PHOTOFRIN RECON SOLN 75 MG
porfimer sodium
BRAND
4
PA
PROLEUKIN RECON SOLN 22000000 UNIT
aldesleukin
BRAND
4
SYLATRON KIT 296 MCG
peginterferon alfa-2b (antineoplastic)
BRAND
4
PA
SYLATRON KIT 4 X 296 MCG
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
SYNRIBO RECON SOLN 3.5 MG
omacetaxine mepesuccinate
BRAND
4
PA
TARGRETIN CAP 75 MG
bexarotene
BRAND
4
PA
THERACYS RECON SUSP 81 MG/VIAL
bcg live intravesical
BRAND
2
PA
tretinoin cap 10 mg
generic
4
TRISENOX SOLUTION 10 MG/10ML
arsenic trioxide
BRAND
4
UVADEX SOLUTION 20 MCG/ML
methoxsalen (photopheresis)
BRAND
2
PAGE 78
TIER
PA
PA
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Chemotherapy Adjuncts**
KEPIVANCE RECON SOLN 6.25 MG
palifermin
BRAND
4
PA
amifostine recon soln 500 mg
generic
1
PA
calcium folinate solution 100 mg/10ml
generic
1
PA
calcium folinate solution 300 mg/30ml
generic
1
PA
dexrazoxane recon soln 250 mg
generic
1
PA
dexrazoxane recon soln 500 mg
generic
1
PA
FUSILEV RECON SOLN 50 MG
levoleucovorin calcium
BRAND
4
leucovorin calcium recon soln 100 mg
generic
1
PA
generic
1
PA
generic
1
PA
generic
1
PA
generic
1
PA
leucovorin calcium solution 10 mg/ml
generic
1
PA
leucovorin calcium tab 10 mg
generic
1
generic
1
generic
1
generic
1
mesna solution 100 mg/ml
generic
4
MESNEX TAB 400 MG
mesna
BRAND
4
TOTECT RECON SOLN 500 MG
dexrazoxane
BRAND
2
VORAXAZE RECON SOLN 1000 UNIT
glucarpidase
BRAND
4
ABRAXANE RECON SUSP 100 MG
paclitaxel protein-bound particles
BRAND
4
PA
DOCEFREZ RECON SOLN 20 MG
docetaxel
BRAND
4
PA
*Chemotherapy Rescue/Antidote Agents**
PA
*Mitotic Inhibitors**
PAGE 79
PRODUCT DESCRIPTION
BRAND/GEN
DOCEFREZ RECON SOLN 80 MG
docetaxel
BRAND
4
PA
DOCETAXEL CONC 140 MG/7ML
docetaxel
BRAND
4
PA
docetaxel
BRAND
4
PA
DOCETAXEL CONC 20 MG/0.5ML
docetaxel
BRAND
2
docetaxel conc 20 mg/ml
generic
4
PA
DOCETAXEL CONC 20 MG/ML
docetaxel
BRAND
4
PA
docetaxel conc 80 mg/4ml
generic
4
PA
docetaxel
BRAND
4
PA
docetaxel solution 160 mg/16ml
generic
4
PA
DOCETAXEL SOLUTION 160 MG/16ML
docetaxel
BRAND
4
PA
generic
4
PA
docetaxel
BRAND
4
PA
generic
4
PA
docetaxel
BRAND
4
PA
ETOPOPHOS RECON SOLN 100 MG
etoposide phosphate
BRAND
2
PA
etoposide cap 50 mg
generic
4
PA
ETOPOSIDE CAP 50 MG
etoposide
BRAND
4
PA
etoposide solution 1 gm/50ml
generic
4
PA
etoposide solution 100 mg/5ml
generic
1
PA
etoposide solution 500 mg/25ml
generic
4
PA
HALAVEN SOLUTION 1 MG/2ML
eribulin mesylate
BRAND
4
PA
IXEMPRA KIT RECON SOLN 15 MG
ixabepilone
BRAND
4
PA
IXEMPRA KIT RECON SOLN 45 MG
BRAND
4
PA
PAGE 80
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ixabepilone
JEVTANA SOLUTION 60 MG/1.5ML
cabazitaxel
BRAND
3
PA
MARQIBO SUSPENSION 5 MG/31ML
vincristine sulfate liposome
BRAND
4
PA
paclitaxel conc 100 mg/16.7ml
generic
4
PA
paclitaxel conc 150 mg/25ml
generic
4
PA
generic
4
PA
generic
4
PA
TAXOTERE CONC 20 MG/0.5ML
docetaxel
BRAND
2
TAXOTERE CONC 20 MG/ML
docetaxel
BRAND
4
PA
TAXOTERE CONC 80 MG/4ML
docetaxel
BRAND
4
PA
TENIPOSIDE SOLUTION 10 MG/ML
teniposide
BRAND
4
PA
toposar solution 1 gm/50ml
generic
4
PA
toposar solution 100 mg/5ml
generic
1
toposar solution 500 mg/25ml
generic
4
PA
vinblastine sulfate recon soln 10 mg
generic
4
PA
vinblastine sulfate solution 1 mg/ml
generic
4
PA
vincasar pfs solution 1 mg/ml
generic
4
PA
vincristine sulfate solution 1 mg/ml
generic
4
PA
vinorelbine tartrate solution 10 mg/ml
generic
4
PA
vinorelbine tartrate solution 50 mg/5ml
generic
4
PA
VUMON SOLUTION 10 MG/ML
teniposide
BRAND
4
PA
CAMPTOSAR SOLUTION 300 MG/15ML
irinotecan hcl
BRAND
4
PA
HYCAMTIN CAP 0.25 MG
topotecan hcl
BRAND
4
PA
4
PA
*Topoisomerase I Inhibitors**
PAGE 81
PRODUCT DESCRIPTION
BRAND/GEN
TIER
HYCAMTIN CAP 1 MG
topotecan hcl
BRAND
irinotecan hcl solution 100 mg/5ml
generic
4
PA
irinotecan hcl solution 40 mg/2ml
generic
4
PA
IRINOTECAN HCL SOLUTION 500 MG/25ML
irinotecan hcl
BRAND
4
PA
topotecan hcl recon soln 4 mg
generic
4
PA
topotecan hcl solution 4 mg/4ml
generic
4
PA
TOPOTECAN HCL SOLUTION 4 MG/4ML
topotecan hcl
BRAND
4
PA
generic
3
benztropine mesylate solution 1 mg/ml
generic
1
benztropine mesylate tab 0.5 mg
generic
1
benztropine mesylate tab 1 mg
generic
1
benztropine mesylate tab 2 mg
generic
1
trihexyphenidyl hcl elixir 0.4 mg/ml
generic
1
trihexyphenidyl hcl tab 2 mg
generic
1
trihexyphenidyl hcl tab 5 mg
generic
1
entacapone tab 200 mg
generic
4
TASMAR TAB 100 MG
tolcapone
BRAND
3
amantadine hcl cap 100 mg
generic
1
amantadine hcl syrup 50 mg/5ml
generic
1
amantadine hcl tab 100 mg
generic
1
bromocriptine mesylate cap 5 mg
generic
1
bromocriptine mesylate tab 2.5 mg
generic
1
carbidopa-levodopa er tab er 25-100 mg
generic
1
carbidopa-levodopa er tab er 50-200 mg
generic
1
*ANTIPARKINSON AGENTS*
*Antiparkinson Adjuvants**
carbidopa tab 25 mg
*Antiparkinson Anticholinergics**
*Antiparkinson COMT Inhibitors**
*Antiparkinson Dopaminergics**
PAGE 82
PRODUCT DESCRIPTION
BRAND/GEN
carbidopa-levodopa tab 10-100 mg
generic
1
generic
1
generic
1
carbidopa-levodopa tab disp 10-100 mg
generic
1
generic
1
generic
1
carbidopa-levodopa-entacapone tab 12.5-50200 mg
generic
1
generic
1
carbidopa-levodopa-entacapone tab 25-100200 mg
generic
1
generic
1
generic
1
carbidopa-levodopa-entacapone tab 50-200200 mg
generic
1
NEUPRO PATCH 24HR 1 MG/24HR
rotigotine
BRAND
3
rotigotine
BRAND
3
rotigotine
BRAND
3
rotigotine
BRAND
3
rotigotine
BRAND
3
rotigotine
BRAND
3
pramipexole dihydrochloride tab 0.125 mg
generic
1
generic
1
generic
1
generic
1
pramipexole dihydrochloride tab 1 mg
generic
1
generic
1
ropinirole hcl tab 0.25 mg
generic
1
PAGE 83
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ropinirole hcl tab 0.5 mg
generic
1
ropinirole hcl tab 1 mg
generic
1
generic
1
generic
1
generic
1
generic
1
AZILECT TAB 0.5 MG
rasagiline mesylate
BRAND
3
AZILECT TAB 1 MG
rasagiline mesylate
BRAND
selegiline hcl cap 5 mg
generic
1
selegiline hcl tab 5 mg
generic
1
lithium carbonate cap 150 mg
generic
1
generic
1
generic
1
lithium carbonate er tab er 300 mg
generic
1
lithium carbonate er tab er 450 mg
generic
1
lithium carbonate powder
generic
1
lithium carbonate tab 300 mg
generic
1
lithium solution 8 meq/5ml
generic
1
EQUETRO CAP ER 12H 100 MG
carbamazepine (antipsychotic)
BRAND
3
BRAND
3
BRAND
3
GEODON RECON SOLN 20 MG
ziprasidone mesylate
BRAND
2
LATUDA TAB 120 MG
lurasidone hcl
BRAND
3
*Antiparkinson Monoamine Oxidase Inhibitors**
QL
30 / 30 days
PA
QL
30 / 30 days
3
PA
*ANTIPSYCHOTICS/ANTIMANIC AGENTS*
*Antimanic Agents**
*Antipsychotics - Misc.**
PAGE 84
ST
PRODUCT DESCRIPTION
BRAND/GEN
TIER
LATUDA TAB 20 MG
lurasidone hcl
BRAND
3
LATUDA TAB 40 MG
lurasidone hcl
BRAND
3
LATUDA TAB 60 MG
lurasidone hcl
BRAND
3
LATUDA TAB 80 MG
lurasidone hcl
BRAND
3
ziprasidone hcl cap 20 mg
generic
1
generic
1
generic
1
generic
1
FANAPT TAB 1 MG
iloperidone
BRAND
3
QL
60 / 30 days
FANAPT TAB 10 MG
iloperidone
BRAND
3
QL
60 / 30 days
FANAPT TAB 12 MG
iloperidone
BRAND
3
QL
60 / 30 days
FANAPT TAB 2 MG
iloperidone
BRAND
3
QL
60 / 30 days
FANAPT TAB 4 MG
iloperidone
BRAND
3
QL
60 / 30 days
FANAPT TAB 6 MG
iloperidone
BRAND
3
QL
60 / 30 days
FANAPT TAB 8 MG
iloperidone
BRAND
3
QL
60 / 30 days
FANAPT TITRATION PACK TAB 1 & 2 & 4 & 6
MG
iloperidone
BRAND
2
INVEGA SUSTENNA SUSPENSION 117
MG/0.75ML
paliperidone palmitate
BRAND
4
ST
MG/ML
BRAND
4
ST
MG/1.5ML
BRAND
4
ST
BRAND
4
ST
*Benzisoxazoles**
PAGE 85
PRODUCT DESCRIPTION
BRAND/GEN
TIER
MG/0.25ML
MG/0.5ML
BRAND
4
ST
INVEGA TAB ER 24H 1.5 MG
paliperidone
BRAND
2
QL
60 / 30 days
INVEGA TAB ER 24H 3 MG
paliperidone
BRAND
2
QL
60 / 30 days
paliperidone
BRAND
2
QL
60 / 30 days
paliperidone
BRAND
2
QL
60 / 30 days
RISPERDAL CONSTA RECON SUSP 12.5 MG
risperidone microspheres
BRAND
4
ST
RISPERDAL CONSTA RECON SUSP 25 MG
BRAND
4
ST
RISPERDAL CONSTA RECON SUSP 37.5 MG
BRAND
4
ST
RISPERDAL CONSTA RECON SUSP 50 MG
BRAND
4
ST
risperidone m-tab tab disp 0.5 mg
generic
1
risperidone m-tab tab disp 1 mg
generic
1
generic
1
generic
1
generic
1
risperidone solution 1 mg/ml
generic
1
risperidone tab 0.25 mg
generic
1
risperidone tab 0.5 mg
generic
1
risperidone tab 1 mg
generic
1
generic
1
generic
1
generic
1
risperidone tab disp 0.25 mg
generic
1
risperidone tab disp 0.5 mg
generic
1
risperidone tab disp 1 mg
generic
1
generic
1
PAGE 86
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
1
generic
1
haloperidol 10 mg
generic
1
haloperidol decanoate solution 100 mg/ml
generic
4
haloperidol decanoate solution 50 mg/ml
generic
4
haloperidol lactate solution 5 mg/ml
generic
4
haloperidol tab 0.5 mg
generic
1
haloperidol tab 1 mg
generic
1
generic
1
generic
1
generic
1
generic
1
clozapine tab 100 mg
generic
1
clozapine tab 200 mg
generic
1
clozapine tab 25 mg
generic
1
clozapine tab 50 mg
generic
1
clozapine tab disp 100 mg
generic
3
clozapine tab disp 12.5 mg
generic
3
clozapine tab disp 25 mg
generic
3
FAZACLO TAB DISP 100 MG
clozapine
BRAND
3
FAZACLO TAB DISP 12.5 MG
clozapine
BRAND
3
clozapine
BRAND
3
clozapine
BRAND
3
clozapine
BRAND
3
loxapine succinate cap 10 mg
generic
1
generic
1
generic
1
*Butyrophenones**
*Dibenzapines**
PAGE 87
PRODUCT DESCRIPTION
BRAND/GEN
generic
1
olanzapine recon soln 10 mg
generic
1
olanzapine tab 10 mg
generic
1
generic
1
olanzapine tab 2.5 mg
generic
1
generic
1
olanzapine tab 5 mg
generic
1
olanzapine tab 7.5 mg
generic
1
olanzapine tab disp 10 mg
generic
1
generic
1
generic
1
generic
1
quetiapine fumarate tab 100 mg
generic
1
generic
1
generic
1
generic
1
generic
1
generic
1
SAPHRIS SL TAB 10 MG
asenapine maleate
BRAND
3
SAPHRIS SL TAB 5 MG
asenapine maleate
BRAND
3
SEROQUEL XR TAB ER 24H 150 MG
quetiapine fumarate
BRAND
3
ST
quetiapine fumarate
BRAND
3
ST
quetiapine fumarate
BRAND
3
ST
quetiapine fumarate
BRAND
3
ST
quetiapine fumarate
BRAND
3
ST
ZYPREXA RELPREVV RECON SUSP 210 MG
olanzapine pamoate
BRAND
4
ST
olanzapine pamoate
BRAND
4
ST
PAGE 88
TIER
ST
PRODUCT DESCRIPTION
BRAND/GEN
TIER
olanzapine pamoate
BRAND
4
chlorpromazine hcl solution 25 mg/ml
generic
1
chlorpromazine hcl tab 10 mg
generic
1
generic
1
generic
1
generic
1
generic
1
compazine suppos 25 mg
generic
1
compro suppos 25 mg
generic
1
fluphenazine decanoate solution 25 mg/ml
generic
1
fluphenazine hcl solution 2.5 mg/ml
generic
1
fluphenazine hcl tab 1 mg
generic
1
generic
1
fluphenazine hcl tab 2.5 mg
generic
1
generic
1
perphenazine tab 16 mg
generic
1
generic
1
generic
1
generic
1
prochlorperazine edisylate solution 5 mg/ml
generic
1
prochlorperazine maleate tab 10 mg
generic
1
prochlorperazine maleate tab 5 mg
generic
1
prochlorperazine suppos 25 mg
generic
1
thioridazine hcl tab 10 mg
generic
1
generic
1
generic
1
generic
1
trifluoperazine hcl tab 1 mg
generic
1
generic
1
generic
1
ST
*Phenothiazines**
PA
1
PAGE 89
PRODUCT DESCRIPTION
BRAND/GEN
generic
TIER
*Quinolinone Derivatives**
QL
ABILIFY DISCMELT TAB DISP 10 MG
aripiprazole
BRAND
ABILIFY DISCMELT TAB DISP 15 MG
aripiprazole
BRAND
ABILIFY MAINTENA RECON SUSP 300 MG
aripiprazole
BRAND
4
ST
ABILIFY MAINTENA RECON SUSP 400 MG
aripiprazole
BRAND
4
ST
ABILIFY SOLUTION 1 MG/ML
aripiprazole
BRAND
2
PA
ABILIFY SOLUTION 9.75 MG/1.3ML
aripiprazole
BRAND
2
ST
ABILIFY TAB 10 MG
aripiprazole
BRAND
2
ABILIFY TAB 15 MG
aripiprazole
BRAND
ABILIFY TAB 2 MG
aripiprazole
BRAND
ABILIFY TAB 20 MG
aripiprazole
BRAND
ABILIFY TAB 30 MG
aripiprazole
BRAND
ABILIFY TAB 5 MG
aripiprazole
BRAND
30 / 30 days
3
PA
QL
30 / 30 days
3
PA
QL
30 / 30 days
PA
QL
30 / 30 days
2
PA
QL
30 / 30 days
2
PA
QL
30 / 30 days
2
PA
QL
30 / 30 days
2
PA
QL
30 / 30 days
2
PA
*Thioxanthenes**
NAVANE CAP 20 MG
thiothixene
BRAND
3
thiothixene cap 1 mg
generic
1
generic
1
generic
1
generic
1
PAGE 90
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*ANTISEPTICS & DISINFECTANTS*
*Chlorine Antiseptics**
PHISOHEX LIQUID 3 %
hexachlorophene
BRAND
2
abacavir sulfate tab 300 mg
generic
1
abacavir-lamivudine-zidovudine tab 300-150300 mg
generic
1
APTIVUS CAP 250 MG
tipranavir
BRAND
2
APTIVUS SOLUTION 100 MG/ML
tipranavir
BRAND
2
ATRIPLA TAB 600-200-300 MG
efavirenz-emtricitabine-tenofovir disoproxil
fumarate
BRAND
2
COMBIVIR TAB 150-300 MG
lamivudine-zidovudine
BRAND
2
COMPLERA TAB 200-25-300 MG
emtricitabine-rilpivirine-tenofovir disoproxil
fumarate
BRAND
2
CRIXIVAN CAP 200 MG
indinavir sulfate
BRAND
2
CRIXIVAN CAP 400 MG
indinavir sulfate
BRAND
2
didanosine cap dr 125 mg
generic
1
generic
1
generic
1
generic
1
EDURANT TAB 25 MG
rilpivirine hcl
BRAND
3
EMTRIVA CAP 200 MG
emtricitabine
BRAND
2
EMTRIVA SOLUTION 10 MG/ML
emtricitabine
BRAND
2
EPIVIR HBV SOLUTION 5 MG/ML
lamivudine
BRAND
4
EPIVIR SOLUTION 10 MG/ML
BRAND
4
*ANTIVIRALS*
*Antiretrovirals**
PAGE 91
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
lamivudine
EPIVIR TAB 150 MG
lamivudine
BRAND
4
EPIVIR TAB 300 MG
lamivudine
BRAND
4
EPZICOM TAB 600-300 MG
abacavir sulfate-lamivudine
BRAND
2
FUZEON KIT 90 MG
enfuvirtide
BRAND
2
INTELENCE TAB 100 MG
etravirine
BRAND
2
INTELENCE TAB 200 MG
etravirine
BRAND
2
INTELENCE TAB 25 MG
etravirine
BRAND
2
INVIRASE CAP 200 MG
saquinavir mesylate
BRAND
2
INVIRASE TAB 500 MG
saquinavir mesylate
BRAND
2
ISENTRESS CHEW TAB 100 MG
raltegravir potassium
BRAND
2
ISENTRESS CHEW TAB 25 MG
BRAND
2
ISENTRESS PACKET 100 MG
BRAND
2
ISENTRESS TAB 400 MG
BRAND
2
KALETRA SOLUTION 400-100 MG/5ML
lopinavir-ritonavir
BRAND
2
KALETRA TAB 100-25 MG
lopinavir-ritonavir
BRAND
2
KALETRA TAB 200-50 MG
lopinavir-ritonavir
BRAND
2
lamivudine tab 100 mg
generic
4
generic
4
generic
4
lamivudine-zidovudine tab 150-300 mg
generic
1
LEXIVA SUSPENSION 50 MG/ML
fosamprenavir calcium
BRAND
2
PAGE 92
PA
PRODUCT DESCRIPTION
BRAND/GEN
LEXIVA TAB 700 MG
fosamprenavir calcium
BRAND
2
nevirapine er tab er 24h 400 mg
generic
1
nevirapine suspension 50 mg/5ml
generic
4
nevirapine tab 200 mg
generic
1
NORVIR CAP 100 MG
ritonavir
BRAND
2
NORVIR SOLUTION 80 MG/ML
ritonavir
BRAND
2
NORVIR TAB 100 MG
ritonavir
BRAND
2
PREZISTA SUSPENSION 100 MG/ML
darunavir ethanolate
BRAND
2
PREZISTA TAB 150 MG
BRAND
2
PREZISTA TAB 400 MG
BRAND
2
PREZISTA TAB 600 MG
BRAND
2
PREZISTA TAB 75 MG
BRAND
2
PREZISTA TAB 800 MG
BRAND
2
RESCRIPTOR TAB 100 MG
delavirdine mesylate
BRAND
2
RESCRIPTOR TAB 200 MG
delavirdine mesylate
BRAND
2
RETROVIR SOLUTION 10 MG/ML
zidovudine
BRAND
3
REYATAZ CAP 100 MG
atazanavir sulfate
BRAND
2
REYATAZ CAP 150 MG
atazanavir sulfate
BRAND
2
REYATAZ CAP 200 MG
atazanavir sulfate
BRAND
2
REYATAZ CAP 300 MG
atazanavir sulfate
BRAND
2
stavudine cap 15 mg
generic
1
stavudine cap 20 mg
generic
1
PAGE 93
TIER
PRODUCT DESCRIPTION
BRAND/GEN
stavudine cap 30 mg
generic
1
stavudine cap 40 mg
generic
1
stavudine recon soln 1 mg/ml
generic
1
STRIBILD TAB 150-150-200-300 MG
elvitegravir-cobicistat-emtricitabine-tenofovir
BRAND
2
SUSTIVA CAP 200 MG
efavirenz
BRAND
2
SUSTIVA CAP 50 MG
efavirenz
BRAND
2
SUSTIVA TAB 600 MG
efavirenz
BRAND
2
TIVICAY TAB 50 MG
dolutegravir sodium
BRAND
3
TRUVADA TAB 200-300 MG
emtricitabine-tenofovir disoproxil fumarate
BRAND
2
VIDEX RECON SOLN 2 GM
didanosine
BRAND
2
VIDEX RECON SOLN 4 GM
didanosine
BRAND
2
VIRACEPT POWDER 50 MG/GM
nelfinavir mesylate
BRAND
2
VIRACEPT TAB 250 MG
nelfinavir mesylate
BRAND
2
VIRACEPT TAB 625 MG
nelfinavir mesylate
BRAND
2
viramune suspension 50 mg/5ml
generic
4
VIREAD POWDER 40 MG/GM
tenofovir disoproxil fumarate
BRAND
2
VIREAD TAB 150 MG
BRAND
2
VIREAD TAB 200 MG
BRAND
2
VIREAD TAB 250 MG
BRAND
2
VIREAD TAB 300 MG
BRAND
2
ZIAGEN TAB 300 MG
abacavir sulfate
BRAND
2
zidovudine cap 100 mg
generic
1
PAGE 94
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
zidovudine syrup 50 mg/5ml
generic
1
zidovudine tab 300 mg
generic
1
cidofovir solution 75 mg/ml
generic
4
PA
ganciclovir sodium recon soln 500 mg
generic
4
PA
VALCYTE RECON SOLN 50 MG/ML
valganciclovir hcl
BRAND
4
PA
VALCYTE TAB 450 MG
valganciclovir hcl
BRAND
3
PA
VISTIDE SOLUTION 75 MG/ML
cidofovir
BRAND
4
PA
adefovir dipivoxil tab 10 mg
generic
4
PA
BARACLUDE SOLUTION 0.05 MG/ML
entecavir
BRAND
4
PA
INCIVEK TAB 375 MG
telaprevir
BRAND
4
PA
INFERGEN INJECTABLE 15 MCG/0.5ML
interferon alfacon-1
BRAND
4
PA
INFERGEN INJECTABLE 9 MCG/0.3ML
interferon alfacon-1
BRAND
4
PA
MODERIBA 1200 DOSE PACK TAB 600 MG
ribavirin (hepatitis c)
BRAND
2
MODERIBA 800 DOSE PACK TAB 400 MG
BRAND
2
MODERIBA MISC 200 & 400 MG
BRAND
2
MODERIBA MISC 400 & 600 MG
BRAND
2
moderiba tab 200 mg
generic
1
OLYSIO CAP 150 MG
simeprevir sodium
BRAND
4
PA
PEG-INTRON KIT 50 MCG/0.5ML
peginterferon alfa-2b
BRAND
4
PA
PEGASYS KIT 180 MCG/0.5ML
peginterferon alfa-2a
BRAND
4
PA
PEGASYS PROCLICK SOLUTION 135
MCG/0.5ML
BRAND
4
PA
*CMV Agents**
*Hepatitis Agents**
PAGE 95
PRODUCT DESCRIPTION
BRAND/GEN
TIER
PEGASYS PROCLICK SOLUTION 180
MCG/0.5ML
BRAND
4
PA
PEGASYS SOLUTION 180 MCG/0.5ML
BRAND
4
PA
PEGASYS SOLUTION 180 MCG/ML
BRAND
4
PA
REBETOL SOLUTION 40 MG/ML
BRAND
2
ribasphere cap 200 mg
generic
1
RIBASPHERE RIBAPAK TAB 200 & 400 MG
BRAND
2
RIBASPHERE RIBAPAK TAB 400 & 600 MG
BRAND
2
RIBASPHERE RIBAPAK TAB 400 MG
BRAND
2
RIBASPHERE RIBAPAK TAB 600 MG
BRAND
2
ribasphere tab 200 mg
generic
1
RIBASPHERE TAB 400 MG
BRAND
2
RIBASPHERE TAB 600 MG
BRAND
2
RIBATAB MISC 400 & 600 MG
BRAND
2
RIBATAB TAB 400 MG
BRAND
2
RIBATAB TAB 600 MG
BRAND
2
ribavirin 200 mg
generic
1
ribavirin cap 200 mg
generic
1
ribavirin tab 200 mg
generic
1
SOVALDI TAB 400 MG
sofosbuvir
BRAND
4
PA
TYZEKA TAB 600 MG
telbivudine
BRAND
3
PA
VICTRELIS CAP 200 MG
boceprevir
BRAND
4
PA
PAGE 96
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Herpes Agents**
acyclovir cap 200 mg
generic
1
acyclovir sodium recon soln 1000 mg
generic
1
PA
acyclovir sodium recon soln 500 mg
generic
1
PA
acyclovir sodium solution 50 mg/ml
generic
1
PA
acyclovir suspension 200 mg/5ml
generic
1
acyclovir tab 400 mg
generic
1
acyclovir tab 800 mg
generic
1
famciclovir tab 125 mg
generic
1
generic
1
generic
1
valacyclovir hcl tab 1 gm
generic
1
valacyclovir hcl tab 500 mg
generic
1
RELENZA DISKHALER AER POW BA 5
MG/BLISTER
zanamivir
BRAND
2
rimantadine hcl tab 100 mg
generic
1
TAMIFLU CAP 30 MG
oseltamivir phosphate
BRAND
2
MFL
1 / 30 days
TAMIFLU CAP 45 MG
BRAND
2
MFL
1 / 30 days
TAMIFLU CAP 75 MG
BRAND
2
MFL
1 / 30 days
TAMIFLU RECON SUSP 12 MG/ML
BRAND
2
MFL
1 / 30 days
TAMIFLU RECON SUSP 6 MG/ML
BRAND
2
MFL
1 / 30 days
CUPRIMINE CAP 250 MG
penicillamine
BRAND
3
DEPEN TITRATABS TAB 250 MG
penicillamine
BRAND
4
SYPRINE CAP 250 MG
BRAND
3
QL
30 / 30 days
QL
20 / 30 days
*Influenza Agents**
*ASSORTED CLASSES*
*Chelating Agents**
PAGE 97
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
trientine hcl
*Enzymes**
XIAFLEX RECON SOLN 0.9 MG
collagenase clostridium histolyticum
BRAND
4
PA
BRAND
4
PA
REVLIMID CAP 10 MG
lenalidomide
BRAND
4
PA
REVLIMID CAP 15 MG
lenalidomide
BRAND
4
PA
REVLIMID CAP 2.5 MG
lenalidomide
BRAND
4
PA
REVLIMID CAP 20 MG
lenalidomide
BRAND
4
PA
REVLIMID CAP 25 MG
lenalidomide
BRAND
4
PA
REVLIMID CAP 5 MG
lenalidomide
BRAND
4
PA
ASTAGRAF XL CAP ER 24H 0.5 MG
tacrolimus
BRAND
2
PA
ASTAGRAF XL CAP ER 24H 1 MG
tacrolimus
BRAND
2
PA
ASTAGRAF XL CAP ER 24H 5 MG
tacrolimus
BRAND
2
PA
AZASAN TAB 100 MG
azathioprine
BRAND
3
AZASAN TAB 75 MG
azathioprine
BRAND
3
azathioprine tab 50 mg
generic
1
CELLCEPT RECON SUSP 200 MG/ML
mycophenolate mofetil
BRAND
2
cyclosporine cap 100 mg
generic
1
cyclosporine cap 25 mg
generic
1
cyclosporine modified cap 100 mg
generic
1
generic
1
*Fecal Incontinence Bulking Agents**
SOLESTA GEL 50-15 MG/ML
dextranomer-sodium hyaluronate
*Immunomodulators**
*Immunosuppressive Agents**
PAGE 98
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
1
cyclosporine modified solution 100 mg/ml
generic
1
cyclosporine solution 100 mg/ml
generic
3
cyclosporine solution 50 mg/ml
generic
1
gengraf cap 100 mg
generic
1
gengraf cap 25 mg
generic
1
gengraf solution 100 mg/ml
generic
1
mycophenolate mofetil cap 250 mg
generic
1
mycophenolate mofetil tab 500 mg
generic
1
mycophenolic acid tab dr 180 mg
generic
1
mycophenolic acid tab dr 360 mg
generic
1
PROGRAF SOLUTION 5 MG/ML
tacrolimus
BRAND
2
RAPAMUNE SOLUTION 1 MG/ML
sirolimus
BRAND
3
SANDIMMUNE SOLUTION 100 MG/ML
cyclosporine
BRAND
3
sirolimus tab 0.5 mg
generic
1
tacrolimus cap 0.5 mg
generic
1
tacrolimus cap 1 mg
generic
1
tacrolimus cap 5 mg
generic
1
THYMOGLOBULIN RECON SOLN 25 MG
anti-thymocyte globulin (rabbit), lymphocyte
immune globulin
BRAND
4
PA
ZORTRESS TAB 0.25 MG
everolimus (immunosuppressant)
BRAND
4
PA
ZORTRESS TAB 0.5 MG
BRAND
4
PA
ZORTRESS TAB 0.75 MG
BRAND
4
PA
generic
1
DELFLEX-LC/2.5% DEXTROSE SOLUTION
peritoneal dialysis solutions
BRAND
2
DIANEAL LOW CALCIUM/1.5% DEX
BRAND
2
PA
*Irrigation Solutions**
lactated ringers solution
*Peritoneal Dialysis Solutions**
PAGE 99
PRODUCT DESCRIPTION
BRAND/GEN
TIER
SOLUTION 344 MOSM/L
DIANEAL PD-2/1.5% DEXTROSE SOLUTION
346 MOSM/L
BRAND
2
396 MOSM/L
BRAND
2
485 MOSM/L
BRAND
2
EXTRANEAL SOLUTION
BRAND
2
ULTRABAG/DIANEAL PD-2/1.5% DEX
SOLUTION 346 MOSM/L
BRAND
2
ULTRABAG/DIANEAL PD-2/2.5% DEX
SOLUTION 396 MOSM/L
BRAND
2
ULTRABAG/DIANEAL PD-2/4.25%DEX
SOLUTION 485 MOSM/L
BRAND
2
ULTRABAG/DIANEAL/1.5% DEXTROSE
SOLUTION
BRAND
2
ULTRABAG/DIANEAL/4.25% DEX SOLUTION
BRAND
2
sodium polystyrene sulfonate suspension 15
gm/60ml
generic
1
gm/120ml
generic
1
gm/200ml
generic
1
generic
3
carvedilol 12.5 mg
generic
1
carvedilol 25 mg
generic
1
*Potassium Removing Resins**
*Prostaglandins**
alprostadil solution 500 mcg/ml
PA
*BETA BLOCKERS*
*Alpha-Beta Blockers**
PAGE 100
PRODUCT DESCRIPTION
BRAND/GEN
TIER
carvedilol 6.25 mg
generic
1
carvedilol tab 12.5 mg
generic
1
carvedilol tab 25 mg
generic
1
generic
1
generic
1
labetalol hcl tab 100 mg
generic
1
generic
1
generic
1
acebutolol hcl cap 200 mg
generic
1
acebutolol hcl cap 400 mg
generic
1
atenolol tab 100 mg
generic
1
atenolol tab 25 mg
generic
1
atenolol tab 50 mg
generic
1
betaxolol hcl tab 10 mg
generic
1
betaxolol hcl tab 20 mg
generic
1
bisoprolol fumarate tab 10 mg
generic
1
bisoprolol fumarate tab 5 mg
generic
1
BYSTOLIC TAB 10 MG
nebivolol hcl
BRAND
3
ST
BYSTOLIC TAB 2.5 MG
nebivolol hcl
BRAND
3
ST
BYSTOLIC TAB 20 MG
nebivolol hcl
BRAND
3
ST
BYSTOLIC TAB 5 MG
nebivolol hcl
BRAND
3
ST
metoprolol succinate er tab er 24h 100 mg
generic
1
generic
1
generic
1
generic
1
metoprolol tartrate tab 100 mg
generic
1
generic
1
generic
1
*Beta Blockers Cardio-Selective**
*Beta Blockers Non-Selective**
PAGE 101
PRODUCT DESCRIPTION
BRAND/GEN
TIER
INNOPRAN XL CAP ER 24H 120 MG
propranolol hcl sustained-release beads
BRAND
3
INNOPRAN XL CAP ER 24H 80 MG
propranolol hcl sustained-release beads
BRAND
3
LEVATOL TAB 20 MG
penbutolol sulfate
BRAND
3
nadolol tab 20 mg
generic
1
nadolol tab 40 mg
generic
1
nadolol tab 80 mg
generic
1
pindolol tab 10 mg
generic
1
pindolol tab 5 mg
generic
1
propranolol hcl er cap er 24h 120 mg
generic
1
generic
1
generic
1
generic
1
propranolol hcl solution 20 mg/5ml
generic
1
propranolol hcl solution 40 mg/5ml
generic
1
propranolol hcl tab 10 mg
generic
1
generic
1
generic
1
generic
1
generic
1
sotalol hcl (af) tab 120 mg
generic
1
generic
1
generic
1
sotalol hcl tab 120 mg
generic
1
generic
1
generic
1
generic
1
timolol maleate tab 10 mg
generic
1
generic
1
generic
1
ST
*CALCIUM CHANNEL BLOCKERS*
PAGE 102
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Calcium Channel Blockers**
afeditab cr tab er 24h 30 mg
generic
1
afeditab cr tab er 24h 60 mg
generic
1
amlodipine besylate 10 mg
generic
1
amlodipine besylate 2.5 mg
generic
1
amlodipine besylate 5 mg
generic
1
amlodipine besylate tab 10 mg
generic
1
amlodipine besylate tab 2.5 mg
generic
1
amlodipine besylate tab 5 mg
generic
1
CARDENE SR CAP ER 12H 30 MG
nicardipine hcl
BRAND
3
nicardipine hcl
BRAND
3
nicardipine hcl
BRAND
3
dilt-cd cap er 24h 120 mg
generic
1
generic
1
generic
1
generic
1
dilt-xr cap er 24h 120 mg
generic
1
generic
1
generic
1
diltiazem hcl cd cap er 24h 360 mg
generic
1
diltiazem hcl er beads cap er 24h 120 mg
generic
1
generic
1
generic
1
generic
1
generic
1
generic
1
diltiazem hcl er cap er 12h 120 mg
generic
1
generic
1
generic
1
generic
1
1
PAGE 103
PRODUCT DESCRIPTION
BRAND/GEN
generic
generic
1
diltiazem hcl er coated beads cap er 24h 120
mg
generic
1
mg
generic
1
mg
generic
1
mg
generic
1
mg
generic
1
diltiazem hcl er coated beads tab er 24h 180
mg
generic
1
mg
generic
1
mg
generic
1
mg
generic
1
mg
generic
1
DILTIAZEM HCL RECON SOLN 100 MG
diltiazem hcl
BRAND
2
PA
diltiazem hcl solution 125 mg/25ml
generic
1
PA
generic
1
PA
generic
1
PA
diltiazem hcl tab 120 mg
generic
1
generic
1
generic
1
generic
1
DYNACIRC CR TAB ER 24H 10 MG
isradipine
BRAND
2
DYNACIRC CR TAB ER 24H 5 MG
isradipine
BRAND
2
felodipine er tab er 24h 10 mg
generic
1
felodipine er tab er 24h 2.5 mg
generic
1
PAGE 104
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
felodipine er tab er 24h 5 mg
generic
1
isradipine cap 2.5 mg
generic
1
isradipine cap 5 mg
generic
1
nicardipine hcl cap 20 mg
generic
1
nicardipine hcl cap 30 mg
generic
1
nifediac cc tab er 24h 30 mg
generic
1
generic
1
generic
1
nifedical xl tab er 24h 30 mg
generic
1
nifedical xl tab er 24h 60 mg
generic
1
nifedipine cap 10 mg
generic
1
nifedipine cap 20 mg
generic
1
nifedipine er osmotic tab er 24h 30 mg
generic
1
generic
1
generic
1
nifedipine er tab er 24h 30 mg
generic
1
generic
1
generic
1
nimodipine cap 30 mg
generic
1
nisoldipine er tab er 24h 17 mg
generic
1
generic
1
nisoldipine er tab er 24h 25.5 mg
generic
1
generic
1
generic
1
generic
1
nisoldipine er tab er 24h 8.5 mg
generic
1
verapamil hcl er cap er 24h 100 mg
generic
1
generic
1
generic
1
generic
1
generic
1
generic
1
1
PAGE 105
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
verapamil hcl er tab er 120 mg
generic
1
generic
1
generic
1
verapamil hcl solution 2.5 mg/ml
generic
1
verapamil hcl tab 120 mg
generic
1
generic
1
generic
1
digox tab 125 mcg
generic
1
digox tab 250 mcg
generic
1
digoxin solution 0.05 mg/ml
generic
1
digoxin tab 125 mcg
generic
1
digoxin tab 250 mcg
generic
1
BRAND
3
CIALIS TAB 10 MG
tadalafil
BRAND
3
QL
8 / 30 days
CIALIS TAB 2.5 MG
tadalafil
BRAND
3
QL
15 / 30 days
CIALIS TAB 20 MG
tadalafil
BRAND
3
QL
8 / 30 days
CIALIS TAB 5 MG
tadalafil
BRAND
3
QL
15 / 30 days
MUSE PELLET 1000 MCG
alprostadil (vasodilator)
QL
BRAND
8 / 30 days
3
MUSE PELLET 125 MCG
BRAND
MUSE PELLET 250 MCG
BRAND
PA
*CARDIOTONICS*
*Cardiac Glycosides**
*CARDIOVASCULAR AGENTS - MISC.*
*Cardiovascular Agents Misc. - Combinations**
BIDIL TAB 20-37.5 MG
isosorbide dinitrate-hydralazine hcl
*Impotence Agents**
PAGE 106
PA
QL
8 / 30 days
3
PA
QL
3
8 / 30 days
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
MUSE PELLET 500 MCG
BRAND
VIAGRA TAB 100 MG
sildenafil citrate
BRAND
3
QL
8 / 30 days
VIAGRA TAB 25 MG
sildenafil citrate
BRAND
3
QL
8 / 30 days
VIAGRA TAB 50 MG
sildenafil citrate
BRAND
3
QL
8 / 30 days
epoprostenol sodium recon soln 0.5 mg
generic
4
PA
epoprostenol sodium recon soln 1.5 mg
generic
4
PA
REMODULIN SOLUTION 1 MG/ML
treprostinil sodium
BRAND
4
PA
treprostinil sodium
BRAND
4
PA
REMODULIN SOLUTION 2.5 MG/ML
treprostinil sodium
BRAND
4
PA
treprostinil sodium
BRAND
4
PA
TYVASO REFILL SOLUTION 0.6 MG/ML
treprostinil
BRAND
4
PA
TYVASO SOLUTION 0.6 MG/ML
treprostinil
BRAND
4
PA
TYVASO STARTER SOLUTION 0.6 MG/ML
treprostinil
BRAND
4
PA
VELETRI RECON SOLN 0.5 MG
epoprostenol sodium
BRAND
4
PA
VELETRI RECON SOLN 1.5 MG
epoprostenol sodium
BRAND
4
PA
QL
8 / 30 days
3
PA
*Prostaglandin Vasodilators**
*Pulmonary Hypertension - Endothelin Receptor Antagonists**
LETAIRIS TAB 10 MG
ambrisentan
BRAND
4
PA
LETAIRIS TAB 5 MG
ambrisentan
BRAND
4
PA
OPSUMIT TAB 10 MG
macitentan
BRAND
4
PA
4
PA
PAGE 107
PRODUCT DESCRIPTION
BRAND/GEN
TRACLEER TAB 125 MG
bosentan
BRAND
TRACLEER TAB 62.5 MG
bosentan
BRAND
TIER
4
PA
PA
*Pulmonary Hypertension - Phosphodiesterase Inhibitors**
ADCIRCA TAB 20 MG
tadalafil (pulmonary hypertension)
BRAND
4
REVATIO SOLUTION 10 MG/12.5ML
sildenafil citrate (pulmonary hypertension)
BRAND
4
sildenafil citrate tab 20 mg
generic
1
cefadroxil cap 500 mg
generic
1
cefadroxil recon susp 250 mg/5ml
generic
1
cefadroxil recon susp 500 mg/5ml
generic
1
cefadroxil tab 1 gm
generic
1
cefazolin sodium 500 mg
generic
1
PA
cefazolin sodium recon soln 1 gm
generic
1
PA
CEFAZOLIN SODIUM RECON SOLN 1 GM
cefazolin sodium
BRAND
2
PA
generic
1
PA
generic
1
PA
cefazolin sodium recon soln 500 mg
generic
1
PA
CEFAZOLIN SODIUM SOLUTION 1-5 GM-%
cefazolin in d5w
BRAND
2
PA
CEFAZOLIN SODIUM-DEXTROSE RECON
SOLN 1-4 GM-%
cefazolin sodium and dextrose
BRAND
2
PA
CEFAZOLIN SODIUM-DEXTROSE RECON
SOLN 2-3 GM-%
cefazolin sodium and dextrose
BRAND
2
PA
cephalexin cap 250 mg
generic
1
cephalexin cap 500 mg
generic
1
cephalexin recon susp 125 mg/5ml
generic
1
cephalexin recon susp 250 mg/5ml
generic
1
PA
*CEPHALOSPORINS*
*Cephalosporins - 1st Generation**
PAGE 108
PRODUCT DESCRIPTION
BRAND/GEN
TIER
cephalexin tab 250 mg
generic
1
cephalexin tab 500 mg
generic
1
CEPHALEXIN TAB 500 MG
cephalexin
BRAND
2
cefaclor cap 250 mg
generic
1
cefaclor cap 500 mg
generic
1
CEFACLOR ER TAB ER 12H 500 MG
cefaclor monohydrate
BRAND
2
cefaclor er tab er 12h 500 mg
generic
1
cefaclor recon susp 125 mg/5ml
generic
1
generic
1
generic
1
cefoxitin sodium recon soln 1 gm
generic
1
PA
cefoxitin sodium recon soln 2 gm
generic
1
PA
cefprozil recon susp 125 mg/5ml
generic
1
cefprozil recon susp 250 mg/5ml
generic
1
cefprozil tab 250 mg
generic
1
cefprozil tab 500 mg
generic
1
CEFTIN RECON SUSP 250 MG/5ML
cefuroxime axetil
BRAND
3
cefuroxime axetil recon susp 125 mg/5ml
generic
1
cefuroxime axetil tab 250 mg
generic
1
cefuroxime axetil tab 500 mg
generic
1
cefuroxime sodium recon soln 1.5 gm
generic
1
PA
cefuroxime sodium recon soln 7.5 gm
generic
1
PA
CEFUROXIME SODIUM RECON SOLN 7.5
GM
cefuroxime sodium
BRAND
2
PA
cefuroxime sodium recon soln 750 mg
generic
1
PA
CEFUROXIME SODIUM-DEXTROSE RECON
SOLN 750-4.1 MG-%
cefuroxime sodium and dextrose
BRAND
2
PA
CEFUROXIME-DEXTROSE RECON SOLN
BRAND
2
PA
*Cephalosporins - 2nd Generation**
PAGE 109
PRODUCT DESCRIPTION
BRAND/GEN
TIER
1.5-2.9 GM-%
cefuroxime sodium and dextrose
ZINACEF RECON SOLN 750 MG
cefuroxime sodium
BRAND
3
cefdinir cap 300 mg
generic
1
cefdinir recon susp 125 mg/5ml
generic
1
cefdinir recon susp 250 mg/5ml
generic
1
cefotaxime sodium recon soln 1 gm
generic
1
PA
generic
1
PA
generic
1
PA
cefotaxime sodium recon soln 500 mg
generic
1
PA
cefpodoxime proxetil recon susp 100 mg/5ml
generic
1
cefpodoxime proxetil recon susp 50 mg/5ml
generic
1
cefpodoxime proxetil tab 100 mg
generic
1
cefpodoxime proxetil tab 200 mg
generic
1
CEFTIBUTEN CAP 400 MG
ceftibuten
BRAND
3
CEFTIBUTEN RECON SUSP 180 MG/5ML
ceftibuten
BRAND
3
CLAFORAN RECON SOLN 2 GM
cefotaxime sodium
BRAND
3
PA
SUPRAX CAP 400 MG
cefixime
BRAND
2
ST
SUPRAX CHEW TAB 100 MG
cefixime
BRAND
2
ST
SUPRAX CHEW TAB 200 MG
cefixime
BRAND
2
ST
SUPRAX RECON SUSP 100 MG/5ML
cefixime
BRAND
2
ST
cefixime
BRAND
2
ST
cefixime
BRAND
2
ST
SUPRAX TAB 400 MG
cefixime
BRAND
2
ST
PA
*Cephalosporins - 3rd Generation**
PAGE 110
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Cephalosporins - 4th Generation**
cefepime hcl recon soln 1 gm
generic
1
PA
cefepime hcl recon soln 2 gm
generic
1
PA
CEFEPIME HCL SOLUTION 1 GM/50ML
cefepime hcl
BRAND
2
PA
CEFEPIME HCL SOLUTION 2 GM/100ML
cefepime hcl
BRAND
2
PA
CEFEPIME-DEXTROSE RECON SOLN 1
GM/50ML
cefepime hcl and dextrose
BRAND
2
PA
CEFEPIME-DEXTROSE RECON SOLN 2
GM/50ML
cefepime hcl and dextrose
BRAND
2
PA
MAXIPIME RECON SOLN 1 GM
cefepime hcl
BRAND
3
PA
MAXIPIME RECON SOLN 2 GM
cefepime hcl
BRAND
3
PA
generic
1
generic
1
altavera tab 0.15-30 mg-mcg
generic
0
GL
Female
alyacen 1/35 tab 1-35 mg-mcg
generic
0
GL
Female
alyacen 7/7/7 tab 0.5/0.75/1-35 mg-mcg
generic
0
GL
Female
amethia lo tab 0.1-0.02 & 0.01 mg
generic
0
GL
Female
amethia tab 0.15-0.03 &0.01 mg
generic
0
GL
Female
AMETHYST TAB 90-20 MCG
levonorgestrel-ethinyl estradiol (continuous)
BRAND
0
GL
Female
apri tab 0.15-30 mg-mcg
generic
0
GL
Female
aranelle tab 0.5/1/0.5-35 mg-mcg
generic
0
GL
Female
aubra tab 0.1-20 mg-mcg
generic
0
GL
Female
*CHEMICALS*
*Bulk Chemicals - K's**
ketorolac tromethamine powder
*Liquids**
ammonium lactate solution 70 %
*CONTRACEPTIVES*
*Combination Contraceptives - Oral**
PAGE 111
PRODUCT DESCRIPTION
BRAND/GEN
aviane tab 0.1-20 mg-mcg
generic
0
GL
Female
azurette tab 0.15-0.02/0.01 mg (21/5)
generic
0
GL
Female
balziva tab 0.4-35 mg-mcg
generic
0
GL
Female
BEYAZ TAB 3-0.02-0.451 MG
drospirenone-ethinyl estradiol-levomefolate
calcium
BRAND
0
GL
Female
briellyn tab 0.4-35 mg-mcg
generic
0
GL
Female
camrese lo tab 0.1-0.02 & 0.01 mg
generic
0
GL
Female
camrese tab 0.15-0.03 &0.01 mg
generic
0
GL
Female
caziant tab 0.1/0.125/0.15 -0.025 mg
generic
0
GL
Female
chateal tab 0.15-30 mg-mcg
generic
0
GL
Female
cryselle-28 tab 0.3-30 mg-mcg
generic
0
GL
Female
cyclafem 1/35 tab 1-35 mg-mcg
generic
0
GL
Female
cyclafem 7/7/7 tab 0.5/0.75/1-35 mg-mcg
generic
0
GL
Female
dasetta 1/35 tab 1-35 mg-mcg
generic
0
GL
Female
dasetta 7/7/7 tab 0.5/0.75/1-35 mg-mcg
generic
0
GL
Female
daysee tab 0.15-0.03 &0.01 mg
generic
0
GL
Female
delyla tab 0.1-20 mg-mcg
generic
0
desogestrel-ethinyl estradiol tab 0.15-0.02/0.01
mg (21/5)
generic
0
desogestrel-ethinyl estradiol tab 0.15-30 mgmcg
generic
0
GL
Female
drospirenone-ethinyl estradiol tab 3-0.03 mg
generic
0
GL
Female
elinest tab 0.3-30 mg-mcg
generic
0
GL
Female
emoquette tab 0.15-30 mg-mcg
generic
0
GL
Female
enpresse-28 tab
generic
0
GL
Female
enskyce tab 0.15-30 mg-mcg
generic
0
GL
Female
estarylla tab 0.25-35 mg-mcg
generic
0
GL
Female
FALESSA KIT 20-1-0.1 MCG-MG
BRAND
0
GL
Female
PAGE 112
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
levonorgestrel-ethinyl estradiol & folic acid
falmina tab 0.1-20 mg-mcg
generic
0
GL
Female
GENERESS FE CHEW TAB 0.8-25 MG-MCG
norethindrone & ethinyl estradiol-fe
BRAND
0
GL
Female
gianvi tab 3-0.02 mg
generic
0
GL
Female
gildagia tab 0.4-35 mg-mcg
generic
0
GL
Female
gildess 1.5/30 tab 1.5-30 mg-mcg
generic
0
GL
Female
gildess 1/20 tab 1-20 mg-mcg
generic
0
GL
Female
gildess fe 1.5/30 tab 1.5-30 mg-mcg
generic
0
GL
Female
gildess fe 1/20 tab 1-20 mg-mcg
generic
0
GL
Female
introvale tab 0.15-0.03 mg
generic
0
GL
Female
jolessa tab 0.15-0.03 mg
generic
0
GL
Female
junel 1.5/30 tab 1.5-30 mg-mcg
generic
0
GL
Female
junel 1/20 tab 1-20 mg-mcg
generic
0
GL
Female
junel fe 1.5/30 tab 1.5-30 mg-mcg
generic
0
GL
Female
junel fe 1/20 tab 1-20 mg-mcg
generic
0
GL
Female
kariva tab 0.15-0.02/0.01 mg (21/5)
generic
0
GL
Female
kelnor 1/35 tab 1-35 mg-mcg
generic
0
GL
Female
kurvelo tab 0.15-30 mg-mcg
generic
0
GL
Female
larin 1.5/30 tab 1.5-30 mg-mcg
generic
0
larin 1/20 tab 1-20 mg-mcg
generic
0
GL
Female
larin fe 1.5/30 tab 1.5-30 mg-mcg
generic
0
GL
Female
larin fe 1/20 tab 1-20 mg-mcg
generic
0
GL
Female
leena tab 0.5/1/0.5-35 mg-mcg
generic
0
GL
Female
lessina tab 0.1-20 mg-mcg
generic
0
GL
Female
levonest tab
generic
0
GL
Female
levonorgest-eth estrad 91-day tab 0.1-0.02 &
0.01 mg
generic
0
GL
Female
levonorgest-eth estrad 91-day tab 0.15-0.03 mg
generic
0
GL
Female
PAGE 113
PRODUCT DESCRIPTION
BRAND/GEN
levonorgestrel-ethinyl estrad tab 0.1-20 mgmcg
generic
0
GL
Female
levonorgestrel-ethinyl estrad tab 0.15-30 mgmcg
generic
0
GL
Female
levora 0.15/30 (28) tab 0.15-30 mg-mcg
generic
0
GL
Female
LO LOESTRIN FE TAB 1 MG-10 MCG / 10
MCG
norethindrone acetate-ethinyl estradiol-fe fum
(biphasic)
BRAND
0
GL
Female
LO MINASTRIN FE THER PACK 1 MG-10
MCG / 10 MCG
norethindrone acetate-ethinyl estradiol-fe fum
(biphasic)
BRAND
0
GL
Female
LOESTRIN 24 FE TAB 1-20 MG-MCG
norethin acet & estrad-fe
BRAND
0
GL
Female
loryna tab 3-0.02 mg
generic
0
GL
Female
low-ogestrel tab 0.3-30 mg-mcg
generic
0
GL
Female
lutera tab 0.1-20 mg-mcg
generic
0
GL
Female
marlissa tab 0.15-30 mg-mcg
generic
0
GL
Female
microgestin 1.5/30 tab 1.5-30 mg-mcg
generic
0
GL
Female
microgestin 1/20 tab 1-20 mg-mcg
generic
0
GL
Female
microgestin fe 1.5/30 tab 1.5-30 mg-mcg
generic
0
GL
Female
microgestin fe 1/20 tab 1-20 mg-mcg
generic
0
GL
Female
MINASTRIN 24 FE CHEW TAB 1-20 MGMCG(24)
norethin acet & estrad-fe
BRAND
0
GL
Female
mono-linyah tab 0.25-35 mg-mcg
generic
0
GL
Female
mononessa tab 0.25-35 mg-mcg
generic
0
GL
Female
myzilra tab
generic
0
GL
Female
NATAZIA TAB 3/2-2/2-3/1 MG
estradiol valerate-dienogest
BRAND
0
GL
Female
necon 0.5/35 (28) tab 0.5-35 mg-mcg
generic
0
GL
Female
necon 1/35 (28) tab 1-35 mg-mcg
generic
0
GL
Female
NECON 1/50 (28) TAB 1-50 MG-MCG
norethindrone & mestranol
BRAND
0
GL
Female
PAGE 114
TIER
PRODUCT DESCRIPTION
BRAND/GEN
NECON 10/11 (28) TAB 35 MCG
norethindrone-eth estradiol (biphasic)
BRAND
0
GL
Female
necon 7/7/7 tab 0.5/0.75/1-35 mg-mcg
generic
0
GL
Female
nikki tab 3-0.02 mg
generic
0
norethin ace-eth estrad-fe tab 1-20 mg-mcg
generic
0
norethindrone acet-ethinyl est tab 1-20 mg-mcg
generic
0
norgestim-eth estrad triphasic tab
0.18/0.215/0.25 mg-35 mcg
generic
0
GL
Female
norgestimate-eth estradiol tab 0.25-35 mg-mcg
generic
0
GL
Female
norgestrel-ethinyl estradiol tab 0.3-30 mg-mcg
generic
0
GL
Female
NORINYL 1+50 (28) TAB 1-50 MG-MCG
norethindrone & mestranol
BRAND
0
GL
Female
nortrel 0.5/35 (28) tab 0.5-35 mg-mcg
generic
0
GL
Female
nortrel 1/35 (21) tab 1-35 mg-mcg
generic
0
GL
Female
nortrel 1/35 (28) tab 1-35 mg-mcg
generic
0
GL
Female
nortrel 7/7/7 tab 0.5/0.75/1-35 mg-mcg
generic
0
GL
Female
ocella tab 3-0.03 mg
generic
0
GL
Female
OGESTREL TAB 0.5-50 MG-MCG
norgestrel & ethinyl estradiol
BRAND
0
GL
Female
orsythia tab 0.1-20 mg-mcg
generic
0
GL
Female
ORTHO TRI-CYCLEN LO TAB 0.18/0.215/0.25
MG-25 MCG
norgestimate-ethinyl estradiol (triphasic)
BRAND
0
GL
Female
OVCON-50 TAB 50-1 MCG-MG
norethindrone & eth estradiol
BRAND
0
GL
Female
philith tab 0.4-35 mg-mcg
generic
0
GL
Female
pimtrea tab 0.15-0.02/0.01 mg (21/5)
generic
0
GL
Female
pirmella 1/35 tab 1-35 mg-mcg
generic
0
GL
Female
pirmella 7/7/7 tab 0.5/0.75/1-35 mg-mcg
generic
0
GL
Female
portia-28 tab 0.15-30 mg-mcg
generic
0
GL
Female
previfem tab 0.25-35 mg-mcg
generic
0
GL
Female
QUARTETTE TAB 42-21-21-7 DAYS
levonorgestrel-ethinyl estradiol (91-day)
BRAND
0
GL
Female
PAGE 115
TIER
PRODUCT DESCRIPTION
BRAND/GEN
quasense tab 0.15-0.03 mg
generic
0
GL
Female
reclipsen tab 0.15-30 mg-mcg
generic
0
GL
Female
SAFYRAL TAB 3-0.03-0.451 MG
drospirenone-ethinyl estradiol-levomefolate
calcium
BRAND
0
GL
Female
solia tab 0.15-30 mg-mcg
generic
0
GL
Female
sprintec 28 tab 0.25-35 mg-mcg
generic
0
GL
Female
sronyx tab 0.1-20 mg-mcg
generic
0
GL
Female
syeda tab 3-0.03 mg
generic
0
GL
Female
tilia fe tab 1-20/1-30/1-35 mg-mcg
generic
0
GL
Female
tri-estarylla tab 0.18/0.215/0.25 mg-35 mcg
generic
0
GL
Female
tri-legest fe tab 1-20/1-30/1-35 mg-mcg
generic
0
GL
Female
tri-linyah tab 0.18/0.215/0.25 mg-35 mcg
generic
0
GL
Female
tri-previfem tab 0.18/0.215/0.25 mg-35 mcg
generic
0
GL
Female
tri-sprintec tab 0.18/0.215/0.25 mg-35 mcg
generic
0
GL
Female
trinessa (28) tab 0.18/0.215/0.25 mg-35 mcg
generic
0
GL
Female
trivora (28) tab
generic
0
GL
Female
velivet tab 0.1/0.125/0.15 -0.025 mg
generic
0
GL
Female
vestura tab 3-0.02 mg
generic
0
GL
Female
viorele tab 0.15-0.02/0.01 mg (21/5)
generic
0
GL
Female
vyfemla tab 0.4-35 mg-mcg
generic
0
GL
Female
wera tab 0.5-35 mg-mcg
generic
0
GL
Female
wymzya fe chew tab 0.4-35 mg-mcg
generic
0
GL
Female
zarah tab 3-0.03 mg
generic
0
GL
Female
zenchent fe chew tab 0.4-35 mg-mcg
generic
0
GL
Female
zenchent tab 0.4-35 mg-mcg
generic
0
GL
Female
zeosa chew tab 0.4-35 mg-mcg
generic
0
GL
Female
zovia 1/35e (28) tab 1-35 mg-mcg
generic
0
GL
Female
PAGE 116
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ZOVIA 1/50E (28) TAB 1-50 MG-MCG
ethynodiol diacet & eth estrad
BRAND
0
GL
Female
generic
0
GL
Female
BRAND
0
GL
Female
BRAND
0
GL
Female
ELLA TAB 30 MG
ulipristal acetate
BRAND
0
GL
Female
levonorgestrel tab 0.75 mg
generic
0
GL
Female
levonorgestrel tab 1.5 mg
generic
0
GL
Female
my way tab 1.5 mg
generic
0
GL
Female
next choice one dose tab 1.5 mg
generic
0
GL
Female
next choice tab 0.75 mg
generic
0
GL
Female
IMPLANON IMPLANT 68 MG
etonogestrel
BRAND
0
NEXPLANON IMPLANT 68 MG
etonogestrel
BRAND
*Combination Contraceptives - Transdermal**
xulane patch wk 150-35 mcg/24hr
*Combination Contraceptives - Vaginal**
NUVARING RING 0.12-0.015 MG/24HR
etonogestrel-ethinyl estradiol
*Copper Contraceptives - IUD**
PARAGARD INTRAUTERINE COPPER IUD
copper (iud)
*Emergency Contraceptives**
*Progestin Contraceptives - Implants**
PA
GL
Female
PA
0
GL
Female
*Progestin Contraceptives - Injectable**
DEPO-SUBQ PROVERA 104 SUSPENSION
104 MG/0.65ML
medroxyprogesterone acetate (contraceptive)
BRAND
0
GL
Female
medroxyprogesterone acetate suspension 150
mg/ml
generic
0
GL
Female
MIRENA IUD 20 MCG/24HR
levonorgestrel (iud)
BRAND
0
GL
Female
SKYLA IUD 13.5 MG
levonorgestrel (iud)
BRAND
0
GL
Female
*Progestin Contraceptives - IUD**
PAGE 117
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Progestin Contraceptives - Oral**
camila tab 0.35 mg
generic
0
GL
Female
errin tab 0.35 mg
generic
0
GL
Female
heather tab 0.35 mg
generic
0
GL
Female
jencycla tab 0.35 mg
generic
0
GL
Female
jolivette tab 0.35 mg
generic
0
GL
Female
lyza tab 0.35 mg
generic
0
GL
Female
nora-be tab 0.35 mg
generic
0
GL
Female
norethindrone tab 0.35 mg
generic
0
GL
Female
norlyroc tab 0.35 mg
generic
0
A-HYDROCORT RECON SOLN 100 MG
hydrocortisone sod succinate
BRAND
2
PA
a-methapred 125 mg
generic
4
PA
a-methapred recon soln 125 mg
generic
4
PA
a-methapred recon soln 40 mg
generic
4
PA
asmalpred plus solution 15 mg/5ml
generic
1
asmalpred solution 15 mg/5ml
generic
1
baycadron elixir 0.5 mg/5ml
generic
1
betamethasone sod phos & acet suspension 6
(3-3) mg/ml
generic
1
budesonide er cap er 24h 3 mg
generic
1
DEPO-MEDROL SUSPENSION 20 MG/ML
methylprednisolone acetate
BRAND
2
dexamethasone elixir 0.5 mg/5ml
generic
1
DEXAMETHASONE INTENSOL CONC 1
MG/ML
dexamethasone
BRAND
2
dexamethasone sodium phosphate solution 10
mg/ml
generic
1
PA
dexamethasone sodium phosphate solution
100 mg/10ml
generic
1
PA
*CORTICOSTEROIDS*
*Glucocorticosteroids**
PAGE 118
PA
PRODUCT DESCRIPTION
BRAND/GEN
dexamethasone sodium phosphate solution
120 mg/30ml
generic
1
PA
mg/5ml
generic
1
PA
mg/ml
generic
1
PA
dexamethasone solution 0.5 mg/5ml
generic
1
dexamethasone tab 0.5 mg
generic
1
generic
1
dexamethasone tab 1 mg
generic
1
generic
1
generic
1
generic
1
generic
1
DEXPAK 13 DAY TAB 1.5 MG
dexamethasone
BRAND
2
DEXPAK 6 DAY TAB 1.5 MG
dexamethasone
BRAND
2
hydrocortisone tab 10 mg
generic
1
generic
1
generic
1
KENALOG SUSPENSION 10 MG/ML
triamcinolone acetonide
BRAND
4
PA
KENALOG SUSPENSION 40 MG/ML
triamcinolone acetonide
BRAND
4
PA
MEDROL TAB 2 MG
methylprednisolone
BRAND
2
methylprednisolone (pak) tab 4 mg
generic
1
methylprednisolone acetate suspension 40
mg/ml
generic
4
PA
methylprednisolone acetate suspension 80
mg/ml
generic
1
PA
methylprednisolone sodium succ recon soln
1000 mg
generic
4
PA
125 mg
generic
4
PA
methylprednisolone sodium succ recon soln 40
mg
generic
4
PA
PAGE 119
TIER
PRODUCT DESCRIPTION
BRAND/GEN
500 mg
generic
4
methylprednisolone tab 16 mg
generic
1
generic
1
generic
1
generic
1
MILLIPRED DP 12-DAY TAB 5 MG
prednisolone
BRAND
3
MILLIPRED DP TAB 5 MG
prednisolone
BRAND
3
MILLIPRED SOLUTION 10 MG/5ML
prednisolone sodium phosphate
BRAND
2
MILLIPRED TAB 5 MG
prednisolone
BRAND
2
ORAPRED ODT TAB DISP 10 MG
BRAND
2
BRAND
2
BRAND
2
prednisolone sodium phosphate solution 15
mg/5ml
generic
1
PREDNISOLONE SODIUM PHOSPHATE
SOLUTION 25 MG/5ML
BRAND
2
prednisolone sodium phosphate solution 6.7 (5
base) mg/5ml
generic
1
prednisolone solution 15 mg/5ml
generic
1
prednisolone syrup 15 mg/5ml
generic
1
prednisone (pak) tab 10 mg
generic
1
prednisone (pak) tab 5 mg
generic
1
PREDNISONE INTENSOL CONC 5 MG/ML
prednisone
BRAND
2
prednisone solution 5 mg/5ml
generic
1
prednisone tab 1 mg
generic
1
prednisone tab 10 mg
generic
1
prednisone tab 2.5 mg
generic
1
generic
1
PAGE 120
TIER
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
prednisone tab 5 mg
generic
1
generic
1
SOLU-CORTEF RECON SOLN 250 MG
hydrocortisone sod succinate
BRAND
2
SOLU-MEDROL RECON SOLN 2 GM
methylprednisolone sod succ
BRAND
2
UCERIS TAB ER 24H 9 MG
budesonide
BRAND
2
VERIPRED 20 SOLUTION 20 MG/5ML
BRAND
2
zema-pak 10 day tab 1.5 mg
generic
1
generic
1
generic
1
generic
1
benzonatate cap 100 mg
generic
1
benzonatate cap 200 mg
generic
1
hydrocodone-homatropine syrup 5-1.5 mg/5ml
generic
1
hydromet syrup 5-1.5 mg/5ml
generic
1
gani-tuss nr liquid 100-10 mg/5ml
generic
1
guaifenesin-codeine solution 100-10 mg/5ml
generic
1
guaifenesin-codeine syrup 100-10 mg/5ml
generic
1
hydrocod polst-cpm polst er liquid er 10-8
mg/5ml
generic
1
myci-gc solution 100-10 mg/5ml
generic
1
promethazine vc plain syrup 6.25-5 mg/5ml
generic
1
PROMETHAZINE VC PLAIN SYRUP 6.25-5
MG/5ML
promethazine & phenylephrine
BRAND
2
promethazine vc syrup 6.25-5 mg/5ml
generic
1
PROMETHAZINE VC SYRUP 6.25-5 MG/5ML
BRAND
2
*Mineralocorticoids**
fludrocortisone acetate tab 0.1 mg
*COUGH/COLD/ALLERGY*
*Antitussives**
*Cough/Cold/Allergy Combinations**
PAGE 121
PRODUCT DESCRIPTION
BRAND/GEN
TIER
promethazine vc/codeine syrup 6.25-5-10
mg/5ml
generic
1
PROMETHAZINE VC/CODEINE SYRUP 6.255-10 MG/5ML
phenyleph-promethazine w/ cod
BRAND
2
promethazine-codeine syrup 6.25-10 mg/5ml
generic
1
promethazine-dm syrup 6.25-15 mg/5ml
generic
1
PROMETHAZINE-PHENYLEPHRINE SYRUP
6.25-5 MG/5ML
BRAND
2
robafen ac syrup 100-10 mg/5ml
generic
1
HYPERSAL NEBU SOLN 3.5 %
sodium chloride (inhalant)
BRAND
2
nebusal nebu soln 3 %
generic
1
NEBUSAL NEBU SOLN 6 %
sodium chloride (inhalant)
BRAND
2
pulmosal nebu soln 7 %
generic
4
sodium chloride nebu soln 0.9 %
generic
1
sodium chloride nebu soln 10 %
generic
1
generic
1
generic
4
acetylcysteine solution 10 %
generic
1
acetylcysteine solution 20 %
generic
1
ABSORICA CAP 10 MG
isotretinoin
BRAND
1
QL
30 / 30 days
ABSORICA CAP 20 MG
isotretinoin
BRAND
1
QL
30 / 30 days
ABSORICA CAP 30 MG
isotretinoin
BRAND
3
QL
30 / 30 days
ABSORICA CAP 40 MG
isotretinoin
BRAND
1
QL
30 / 30 days
acne medication 5 gel 5 %
generic
1
*Misc. Respiratory Inhalants**
*Mucolytics**
*DERMATOLOGICALS*
*Acne Products**
1
PAGE 122
PRODUCT DESCRIPTION
BRAND/GEN
adapalene cream 0.1 %
generic
adapalene gel 0.1 %
generic
1
amnesteem cap 10 mg
generic
1
QL
30 / 30 days
amnesteem cap 20 mg
generic
1
QL
30 / 30 days
amnesteem cap 40 mg
generic
1
QL
30 / 30 days
avar-e green cream 10-5 %
generic
1
avita cream 0.025 %
generic
1
avita gel 0.025 %
generic
1
AZELEX CREAM 20 %
azelaic acid (acne)
BRAND
3
benprox liquid 5.25 %
generic
1
benzepro foam 5.3 %
generic
1
benzepro short contact foam 9.8 %
generic
1
benzoyl peroxide cleanser lotion 3 %
generic
1
generic
1
generic
1
benzoyl peroxide cleansing lotion 4 %
generic
1
benzoyl peroxide cream 3.5 %
generic
1
generic
3
generic
1
benzoyl peroxide creamy wash kit 4 %
generic
1
benzoyl peroxide creamy wash kit 8 %
generic
1
benzoyl peroxide creamy wash liquid 4 %
generic
1
benzoyl peroxide creamy wash liquid 8 %
generic
1
benzoyl peroxide foam 5.3 %
generic
1
benzoyl peroxide foam 9.8 %
generic
1
benzoyl peroxide gel 10 %
generic
1
benzoyl peroxide gel 2.5 %
generic
1
benzoyl peroxide gel 5 %
generic
1
benzoyl peroxide liquid 4.25 %
generic
1
benzoyl peroxide pad 3 %
generic
1
generic
1
PAGE 123
TIER
PRODUCT DESCRIPTION
BRAND/GEN
generic
1
benzoyl peroxide short contact foam 9.8 %
generic
1
benzoyl peroxide wash liquid 10 %
generic
1
benzoyl peroxide wash liquid 2.5 %
generic
1
generic
1
generic
1
benzoyl peroxide-erythromycin gel 5-3 %
generic
1
bp 10-1 emulsion 10-1 %
generic
1
bp cleanser liquid 4.25 %
generic
1
bp foam foam 9.8 %
generic
1
bp wash liquid 2.5 %
generic
1
bp wash liquid 5.25 %
generic
1
bp wash liquid 7 %
generic
1
cerisa wash emulsion 10-1 %
generic
1
claravis cap 10 mg
generic
1
QL
30 / 30 days
claravis cap 20 mg
generic
1
QL
30 / 30 days
CLARAVIS CAP 30 MG
isotretinoin
BRAND
3
QL
30 / 30 days
claravis cap 40 mg
generic
1
QL
30 / 30 days
clenia cream 10-5 %
generic
1
clenia foaming wash emulsion 10-5 %
generic
1
CLINDAGEL GEL 1 %
clindamycin phosphate (topical)
BRAND
2
clindamax gel 1 %
generic
1
clindamax lotion 1 %
generic
1
clindamycin phos-benzoyl perox gel 1-5 %
generic
1
clindamycin phos-benzoyl perox gel 1.2-5 %
generic
1
clindamycin phosphate foam 1 %
generic
1
clindamycin phosphate gel 1 %
generic
1
clindamycin phosphate lotion 1 %
generic
1
clindamycin phosphate solution 1 %
generic
1
clindamycin phosphate swab 1 %
generic
1
DIFFERIN LOTION 0.1 %
BRAND
2
PAGE 124
TIER
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
adapalene
EPIDUO GEL 0.1-2.5 %
adapalene-benzoyl peroxide
BRAND
3
ery pad 2 %
generic
1
ERYTHROMYCIN GEL 2 %
erythromycin (acne aid)
BRAND
2
erythromycin gel 2 %
generic
1
erythromycin pad 2 %
generic
1
erythromycin solution 2 %
generic
1
myorisan cap 10 mg
generic
1
QL
30 / 30 days
myorisan cap 20 mg
generic
1
QL
30 / 30 days
myorisan cap 40 mg
generic
1
QL
30 / 30 days
NEOBENZ MICRO PLUS PACK CREAM 5.5 %
benzoyl peroxide
BRAND
3
NEOBENZ MICRO SD CREAM 5.5 %
benzoyl peroxide
BRAND
3
oscion cleanser lotion 6 %
generic
1
oscion cleanser lotion 9 %
generic
1
pr benzoyl peroxide wash liquid 7 %
generic
1
prascion emulsion 10-5 %
generic
1
rosaderm emulsion 10-5 %
generic
1
rosaderm kit 10-5 %
generic
1
rosanil cleanser emulsion 10-5 %
generic
1
se 10-5 ss cream 10-5 %
generic
1
se bpo foaming cloths misc 3 %
generic
1
generic
1
generic
1
se bpo wash liquid 7 %
generic
1
sotret cap 10 mg
generic
1
QL
30 / 30 days
sotret cap 20 mg
generic
1
QL
30 / 30 days
sotret cap 30 mg
generic
1
QL
30 / 30 days
sulfacetamide sod-sulfur wash emulsion 10-5
%
generic
1
PAGE 125
PRODUCT DESCRIPTION
BRAND/GEN
TIER
sulfacetamide sodium (acne) lotion 10 %
generic
1
sulfacetamide sodium suspension 10 %
generic
1
sulfacetamide sodium-sulfur cream 10-2 %
generic
1
sulfacetamide sodium-sulfur cream 10-5 %
generic
1
sulfacetamide sodium-sulfur emulsion 10-5 %
generic
1
sulfacetamide sodium-sulfur foam 10-5 %
generic
1
sulfacetamide sodium-sulfur liquid 10-2 %
generic
1
sulfacetamide sodium-sulfur liquid 9-4 %
generic
1
sulfacetamide sodium-sulfur liquid 9-4.5 %
generic
1
sulfacetamide sodium-sulfur lotion 10-5 %
generic
1
sulfacetamide sodium-sulfur pad 10-5 %
generic
1
sulfacetamide sodium-sulfur suspension 10-5
%
generic
1
sulfacetamide sodium-sulfur suspension 8-4 %
generic
1
sulfacleanse 8/4 suspension 8-4 %
generic
1
tl bpo mx cleanser liquid 4.25 %
generic
1
topisulf cream 10-5 %
generic
1
tretinoin cream 0.025 %
generic
1
generic
1
generic
1
tretinoin gel 0.01 %
generic
1
tretinoin gel 0.025 %
generic
1
tretinoin microsphere gel 0.04 %
generic
1
tretinoin microsphere gel 0.1 %
generic
1
tretinoin microsphere pump gel 0.04 %
generic
1
tretinoin microsphere pump gel 0.1 %
generic
1
virti-sulf cream 10-5 %
generic
1
zenatane cap 10 mg
generic
1
QL
30 / 30 days
zenatane cap 20 mg
generic
1
QL
30 / 30 days
zenatane cap 40 mg
generic
1
QL
30 / 30 days
zencia liquid 9-4 %
generic
1
*Agents for External Genital and Perianal Warts**
PAGE 126
PRODUCT DESCRIPTION
BRAND/GEN
TIER
VEREGEN OINTMENT 15 %
sinecatechins
BRAND
4
BRAND
2
QL
ALTABAX OINTMENT 1 %
retapamulin
BRAND
3
PA
CORTISPORIN OINTMENT 1 %
bacitracin-polymyxin-neomycin hc
BRAND
3
gentamicin sulfate cream 0.1 %
generic
1
gentamicin sulfate ointment 0.1 %
generic
1
mupirocin calcium cream 2 %
generic
1
mupirocin ointment 2 %
generic
1
ciclodan cream 0.77 %
generic
1
ciclodan solution 8 %
generic
1
ciclopirox gel 0.77 %
generic
1
ciclopirox olamine cream 0.77 %
generic
1
ciclopirox olamine suspension 0.77 %
generic
1
ciclopirox shampoo 1 %
generic
1
ciclopirox solution 8 %
generic
1
ciclopirox treatment kit 8 %
generic
1
clotrimazole cream 1 %
generic
1
clotrimazole solution 1 %
generic
1
clotrimazole-betamethasone cream 1-0.05 %
generic
1
clotrimazole-betamethasone lotion 1-0.05 %
generic
1
econazole nitrate cream 1 %
generic
1
ERTACZO CREAM 2 %
sertaconazole nitrate
BRAND
3
PA
EXELDERM CREAM 1 %
sulconazole nitrate
BRAND
3
PA
EXELDERM SOLUTION 1 %
sulconazole nitrate
BRAND
2
PA
ketoconazole cream 2 %
generic
1
*Anti-inflammatory Agents - Topical**
VOLTAREN GEL 1 %
diclofenac sodium (topical)
300 / 30 days
*Antibiotics - Topical**
*Antifungals - Topical**
PAGE 127
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ketoconazole foam 2 %
generic
1
ketoconazole shampoo 2 %
generic
1
kuric 2 %
generic
1
MENTAX CREAM 1 %
butenafine hcl
BRAND
3
NAFTIN CREAM 1 %
naftifine hcl
BRAND
2
NAFTIN CREAM 2 %
naftifine hcl
BRAND
2
NAFTIN GEL 1 %
naftifine hcl
BRAND
3
NAFTIN GEL 2 %
naftifine hcl
BRAND
3
nyamyc powder 100000 unit/gm
generic
1
nystatin cream 100000 unit/gm
generic
1
nystatin ointment 100000 unit/gm
generic
1
nystatin powder 100000 unit/gm
generic
1
nystatin-triamcinolone cream 100000-0.1
unit/gm-%
generic
1
NYSTATIN-TRIAMCINOLONE CREAM
100000-0.1 UNIT/GM-%
nystatin-triamcinolone
BRAND
2
nystatin-triamcinolone ointment 100000-0.1
unit/gm-%
generic
1
nystop powder 100000 unit/gm
generic
1
OXISTAT CREAM 1 %
oxiconazole nitrate
BRAND
3
OXISTAT LOTION 1 %
oxiconazole nitrate
BRAND
2
pedi-dri powder 100000 unit/gm
generic
1
PEDIPIROX-4 NAIL KIT 8 %
ciclopirox
BRAND
2
*Antineoplastic or Premalignant Lesion Agents - Topical**
fluorouracil cream 5 %
generic
1
fluorouracil solution 2 %
generic
1
fluorouracil solution 5 %
generic
1
PICATO GEL 0.015 %
BRAND
3
PAGE 128
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ingenol mebutate
PICATO GEL 0.05 %
ingenol mebutate
BRAND
3
TARGRETIN GEL 1 %
bexarotene (topical)
BRAND
4
PA
VALCHLOR GEL 0.016 %
mechlorethamine hcl (topical)
BRAND
2
PA
PRUDOXIN CREAM 5 %
doxepin hcl (antipruritic)
BRAND
3
ZONALON CREAM 5 %
doxepin hcl (antipruritic)
BRAND
3
8-MOP CAP 10 MG
methoxsalen
BRAND
2
PA
acitretin cap 10 mg
generic
3
PA
acitretin cap 17.5 mg
generic
3
PA
acitretin cap 25 mg
generic
3
PA
calcipotriene cream 0.005 %
generic
3
calcipotriene ointment 0.005 %
generic
1
calcipotriene solution 0.005 %
generic
1
calcitrene ointment 0.005 %
generic
1
calcitriol ointment 3 mcg/gm
generic
3
SORIATANE CAP 22.5 MG
acitretin
BRAND
2
PA
TAZORAC CREAM 0.05 %
tazarotene
BRAND
2
PA
TAZORAC CREAM 0.1 %
tazarotene
BRAND
2
PA
TAZORAC GEL 0.05 %
tazarotene
BRAND
2
PA
TAZORAC GEL 0.1 %
tazarotene
BRAND
2
PA
VECTICAL OINTMENT 3 MCG/GM
calcitriol (topical)
BRAND
3
*Antipruritics - Topical**
*Antipsoriatics**
*Antiseborrheic Products**
PAGE 129
PRODUCT DESCRIPTION
BRAND/GEN
TIER
re 10 wash liquid 10 %
generic
3
seb-prev wash liquid 10 %
generic
3
selenium sulfide lotion 2.5 %
generic
1
sodium sulfacetamide shampoo 10 %
generic
1
sulfacetamide sodium gel 10 % (cleans)
generic
1
sulfacetamide sodium liquid 10 %
generic
3
sulfacetamide sodium powder
generic
1
acyclovir ointment 5 %
generic
1
DENAVIR CREAM 1 %
penciclovir
BRAND
3
ZOVIRAX CREAM 5 %
acyclovir topical
BRAND
2
mafenide acetate packet 5 %
generic
1
silver sulfadiazine cream 1 %
generic
1
ssd af cream 1 %
generic
1
ssd cream 1 %
generic
1
thermazene cream 1 %
generic
1
ala cort cream 1 %
generic
1
alclometasone dipropionate cream 0.05 %
generic
1
alclometasone dipropionate ointment 0.05 %
generic
1
beta-val cream 0.1 %
generic
1
beta-val lotion 0.1 %
generic
1
betamethasone dipropionate aug cream 0.05 %
generic
1
betamethasone dipropionate aug gel 0.05 %
generic
1
betamethasone dipropionate aug lotion 0.05 %
generic
1
betamethasone dipropionate aug ointment 0.05
%
generic
1
betamethasone dipropionate cream 0.05 %
generic
1
betamethasone dipropionate lotion 0.05 %
generic
1
betamethasone dipropionate ointment 0.05 %
generic
1
*Antivirals - Topical**
PA
*Burn Products**
*Corticosteroids - Topical**
1
PAGE 130
PRODUCT DESCRIPTION
BRAND/GEN
betamethasone valerate cream 0.1 %
generic
betamethasone valerate foam 0.12 %
generic
1
betamethasone valerate lotion 0.1 %
generic
1
betamethasone valerate ointment 0.1 %
generic
1
BETAMETHASONE VALERATE OINTMENT
0.1 %
betamethasone valerate
BRAND
2
calcipotriene-betameth diprop ointment 0.0050.064 %
generic
1
clobetasol propionate cream 0.05 %
generic
1
clobetasol propionate foam 0.05 %
generic
1
clobetasol propionate gel 0.05 %
generic
1
clobetasol propionate lotion 0.05 %
generic
1
clobetasol propionate ointment 0.05 %
generic
1
clobetasol propionate shampoo 0.05 %
generic
1
clobetasol propionate solution 0.05 %
generic
1
clocortolone pivalate cream 0.1 %
generic
3
clocortolone pivalate pump cream 0.1 %
generic
3
CLODERM CREAM 0.1 %
clocortolone pivalate
BRAND
3
cormax ointment 0.05 %
generic
1
cormax scalp application solution 0.05 %
generic
1
cormax solution 0.05 %
generic
1
DERMA-SMOOTHE/FS BODY OIL 0.01 %
fluocinolone acetonide
BRAND
3
DERMA-SMOOTHE/FS SCALP OIL 0.01 %
fluocinolone acetonide
BRAND
3
desonide cream 0.05 %
generic
1
desonide lotion 0.05 %
generic
1
desonide ointment 0.05 %
generic
1
DESOXIMETASONE CREAM 0.05 %
desoximetasone
BRAND
2
desoximetasone cream 0.25 %
generic
1
desoximetasone gel 0.05 %
generic
1
DESOXIMETASONE OINTMENT 0.05 %
desoximetasone
BRAND
2
PAGE 131
TIER
PRODUCT DESCRIPTION
BRAND/GEN
desoximetasone ointment 0.25 %
generic
1
DIFLORASONE DIACETATE CREAM 0.05 %
diflorasone diacetate
BRAND
2
diflorasone diacetate ointment 0.05 %
generic
1
FIRST-HYDROCORTISONE GEL 10 %
hydrocortisone (topical)
BRAND
3
fluocinolone acetonide body oil 0.01 %
generic
3
fluocinolone acetonide cream 0.01 %
generic
1
fluocinolone acetonide cream 0.025 %
generic
1
fluocinolone acetonide ointment 0.025 %
generic
1
fluocinolone acetonide scalp oil 0.01 %
generic
3
fluocinolone acetonide solution 0.01 %
generic
1
fluocinonide cream 0.05 %
generic
1
fluocinonide cream 0.1 %
generic
1
fluocinonide gel 0.05 %
generic
1
fluocinonide ointment 0.05 %
generic
1
fluocinonide solution 0.05 %
generic
1
fluticasone propionate cream 0.05 %
generic
1
fluticasone propionate lotion 0.05 %
generic
1
fluticasone propionate ointment 0.005 %
generic
1
halobetasol propionate cream 0.05 %
generic
1
halobetasol propionate ointment 0.05 %
generic
1
hydrocortisone ace-pramoxine cream 2.5-1 %
generic
3
hydrocortisone acetate lotion 2 %
generic
1
hydrocortisone butyr lipo base cream 0.1 %
generic
1
hydrocortisone butyrate cream 0.1 %
generic
1
hydrocortisone butyrate ointment 0.1 %
generic
1
hydrocortisone butyrate solution 0.1 %
generic
1
hydrocortisone cream 1 %
generic
1
hydrocortisone cream 2.5 %
generic
1
hydrocortisone lotion 2.5 %
generic
1
hydrocortisone ointment 1 %
generic
1
hydrocortisone ointment 2.5 %
generic
1
PAGE 132
TIER
PRODUCT DESCRIPTION
BRAND/GEN
hydrocortisone powder
generic
1
hydrocortisone valerate cream 0.2 %
generic
1
hydrocortisone valerate ointment 0.2 %
generic
1
lokara lotion 0.05 %
generic
1
LUXIQ FOAM 0.12 %
betamethasone valerate
BRAND
2
mometasone furoate cream 0.1 %
generic
1
mometasone furoate ointment 0.1 %
generic
1
mometasone furoate solution 0.1 %
generic
1
prednicarbate cream 0.1 %
generic
1
prednicarbate ointment 0.1 %
generic
1
scalacort lotion 2 %
generic
1
TACLONEX SUSPENSION 0.005-0.064 %
calcipotriene-betamethasone dipropionate
BRAND
3
TOPICORT CREAM 0.05 %
desoximetasone
BRAND
2
TOPICORT OINTMENT 0.05 %
desoximetasone
BRAND
2
triamcinolone acetonide cream 0.025 %
generic
1
generic
1
generic
1
triamcinolone acetonide lotion 0.025 %
generic
1
triamcinolone acetonide lotion 0.1 %
generic
1
triamcinolone acetonide ointment 0.025 %
generic
1
generic
1
TRIAMCINOLONE ACETONIDE OINTMENT
0.5 %
triamcinolone acetonide (topical)
BRAND
2
generic
1
TRIAMCINOLONE IN ABSORBASE
OINTMENT 0.05 %
BRAND
2
TRIANEX OINTMENT 0.05 %
BRAND
2
triderm cream 0.1 %
generic
1
VERDESO FOAM 0.05 %
BRAND
2
PAGE 133
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
desonide
*Enzymes - Topical**
SANTYL OINTMENT 250 UNIT/GM
collagenase
BRAND
2
BOTOX COSMETIC RECON SOLN 100 UNIT
onabotulinumtoxina (cosmetic)
BRAND
4
BOTOX COSMETIC RECON SOLN 50 UNIT
onabotulinumtoxina (cosmetic)
BRAND
4
DYSPORT (GLABELLAR LINES) RECON
SOLN 300 UNIT
abobotulinumtoxina (glabellar lines)
BRAND
4
generic
3
ELIDEL CREAM 1 %
pimecrolimus
BRAND
3
PROTOPIC OINTMENT 0.03 %
tacrolimus (topical)
BRAND
PROTOPIC OINTMENT 0.1 %
tacrolimus (topical)
BRAND
*Glabellar Lines (Frown Lines) Agents**
*Immunomodulating Agents - Topical**
imiquimod cream 5 %
*Immunosuppressive Agents - Topical**
QL
30 / 30 days
ST
QL
30 / 30 days
3
ST
QL
30 / 30 days
3
ST
*Keratolytic/Antimitotic Agents**
aliclen shampoo 6 %
generic
1
podofilox solution 0.5 %
generic
1
re sa cream 6 %
generic
1
re sa lotion 6 %
generic
1
salacyn cream 6 %
generic
1
salacyn lotion 6 %
generic
1
salicylic acid cream 6 %
generic
1
salicylic acid foam 6 %
generic
1
salicylic acid gel 6 %
generic
1
salicylic acid lotion 6 %
generic
1
salicylic acid shampoo 6 %
generic
1
PAGE 134
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Local Anesthetics - Topical**
lidocaine hcl cream 3 %
generic
1
lidocaine hcl gel 2 %
generic
1
lidocaine hcl lotion 3 %
generic
1
lidocaine hcl solution 4 %
generic
1
lidocaine ointment 5 %
generic
1
lidocaine patch 5 %
generic
1
lidocaine-prilocaine cream 2.5-2.5 %
generic
1
lidocaine-prilocaine kit 2.5-2.5 %
generic
1
QUTENZA (2 PATCH) KIT 8 %
capsaicin & cleansing gel
BRAND
2
PA
QUTENZA KIT 8 %
capsaicin & cleansing gel
BRAND
2
PA
SYNERA PATCH 70-70 MG
lidocaine-tetracaine
BRAND
3
PA
BRAND
3
PA
BRAND
2
acticin cream 5 %
generic
1
EURAX CREAM 10 %
crotamiton
BRAND
3
EURAX LOTION 10 %
crotamiton
BRAND
2
lindane lotion 1 %
generic
1
lindane shampoo 1 %
generic
1
malathion lotion 0.5 %
generic
1
permethrin cream 5 %
generic
1
SPINOSAD SUSPENSION 0.9 %
spinosad
BRAND
2
ULESFIA LOTION 5 %
benzyl alcohol (pediculicide)
BRAND
3
PA
*Pigmenting-Depigmenting Agents**
OXSORALEN LOTION 1 %
methoxsalen (topical)
*Rosacea Agents**
FINACEA GEL 15 %
azelaic acid
*Scabicides & Pediculicides**
PAGE 135
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Wound Care Products**
APLIGRAF DISK
cultured skin substitute
BRAND
4
REGRANEX GEL 0.01 %
becaplermin
BRAND
2
cosyntropin recon soln 0.25 mg
generic
4
THYROGEN RECON SOLN 1.1 MG
thyrotropin alfa
BRAND
4
PA
TRUETEST TEST STRIP
glucose blood
BRAND
2
C
Copayment may vary
based on plan
TRUETRACK TEST STRIP
glucose blood
BRAND
2
C
Copayment may vary
based on plan
CREON CP DR PART 12000 UNIT
pancrelipase (lipase-protease-amylase)
BRAND
3
BRAND
3
CREON CP DR PART 3000-9500 UNIT
BRAND
3
BRAND
3
BRAND
3
PANCREAZE CP DR PART 10500 UNIT
BRAND
3
BRAND
3
BRAND
3
BRAND
3
pancrelipase (lip-prot-amyl) cp dr part 5000 unit
generic
1
PERTZYE CP DR PART 16000 UNIT
BRAND
3
*DIAGNOSTIC PRODUCTS*
*Diagnostic Drugs**
*Diagnostic Tests**
*DIGESTIVE AIDS*
*Digestive Enzymes**
PAGE 136
PRODUCT DESCRIPTION
BRAND/GEN
TIER
PERTZYE CP DR PART 8000 UNIT
BRAND
3
SUCRAID SOLUTION 8500 UNIT/ML
sacrosidase
BRAND
2
ULTRESA CP DR PART 13800 UNIT
BRAND
3
BRAND
3
BRAND
3
VIOKACE TAB 10440 UNIT
BRAND
3
VIOKACE TAB 20880 UNIT
BRAND
3
ZENPEP CP DR PART 10000 UNIT
BRAND
2
BRAND
2
BRAND
2
BRAND
2
ZENPEP CP DR PART 3000-10000 UNIT
BRAND
2
zenpep cp dr part 5000 unit
generic
1
acetazolamide er cap er 12h 500 mg
generic
1
acetazolamide tab 125 mg
generic
1
acetazolamide tab 250 mg
generic
1
methazolamide tab 25 mg
generic
1
methazolamide tab 50 mg
generic
1
ALDACTAZIDE TAB 50-50 MG
spironolactone & hydrochlorothiazide
BRAND
3
amiloride-hydrochlorothiazide tab 5-50 mg
generic
1
spironolactone-hctz tab 25-25 mg
generic
1
PA
*DIURETICS*
*Carbonic Anhydrase Inhibitors**
*Diuretic Combinations**
1
PAGE 137
PRODUCT DESCRIPTION
BRAND/GEN
TIER
triamterene-hctz cap 37.5-25 mg
generic
triamterene-hctz cap 50-25 mg
generic
1
triamterene-hctz tab 37.5-25 mg
generic
1
triamterene-hctz tab 75-50 mg
generic
1
bumetanide tab 0.5 mg
generic
1
bumetanide tab 1 mg
generic
1
bumetanide tab 2 mg
generic
1
EDECRIN TAB 25 MG
ethacrynic acid
BRAND
3
furosemide solution 10 mg/ml
generic
1
furosemide solution 40 mg/4ml
generic
1
furosemide solution 8 mg/ml
generic
1
furosemide tab 20 mg
generic
1
generic
1
generic
1
torsemide tab 10 mg
generic
1
torsemide tab 100 mg
generic
1
torsemide tab 20 mg
generic
1
torsemide tab 5 mg
generic
1
amiloride hcl tab 5 mg
generic
1
DYRENIUM CAP 100 MG
triamterene
BRAND
3
PA
DYRENIUM CAP 50 MG
triamterene
BRAND
3
PA
spironolactone tab 100 mg
generic
1
generic
1
generic
1
chlorothiazide tab 250 mg
generic
1
chlorothiazide tab 500 mg
generic
1
chlorthalidone tab 25 mg
generic
1
*Loop Diuretics**
*Potassium Sparing Diuretics**
*Thiazides and Thiazide-Like Diuretics**
2
PAGE 138
PRODUCT DESCRIPTION
BRAND/GEN
TIER
CHLORTHALIDONE TAB 25 MG
chlorthalidone
BRAND
chlorthalidone tab 50 mg
generic
1
DIURIL SUSPENSION 250 MG/5ML
chlorothiazide
BRAND
2
hydrochlorothiazide cap 12.5 mg
generic
1
hydrochlorothiazide tab 12.5 mg
generic
1
hydrochlorothiazide tab 25 mg
generic
1
hydrochlorothiazide tab 50 mg
generic
1
indapamide tab 1.25 mg
generic
1
indapamide tab 2.5 mg
generic
1
metolazone tab 10 mg
generic
1
metolazone tab 2.5 mg
generic
1
metolazone tab 5 mg
generic
1
*ENDOCRINE AND METABOLIC AGENTS - MISC.*
*Bone Density Regulators**
alendronate sodium tab 10 mg
generic
1
QL
30 / 30 days
generic
1
QL
4 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
4 / 30 days
calcitonin (salmon) solution 200 unit/act
generic
1
FORTEO SOLUTION 600 MCG/2.4ML
teriparatide (recombinant)
BRAND
4
FORTICAL SOLUTION 200 UNIT/ACT
calcitonin (salmon)
BRAND
2
ibandronate sodium solution 3 mg/3ml
generic
1
ibandronate sodium tab 150 mg
generic
1
pamidronate disodium recon soln 30 mg
generic
4
PA
pamidronate disodium recon soln 90 mg
generic
4
PA
pamidronate disodium solution 30 mg/10ml
generic
4
PA
PAMIDRONATE DISODIUM SOLUTION 6
BRAND
4
PA
PAGE 139
PA
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
MG/ML
pamidronate disodium
pamidronate disodium solution 90 mg/10ml
generic
4
PA
PROLIA SOLUTION 60 MG/ML
denosumab
BRAND
4
PA
SKELID TAB 200 MG
tiludronate disodium
BRAND
3
XGEVA SOLUTION 120 MG/1.7ML
denosumab
BRAND
4
PA
zoledronic acid conc 4 mg/5ml
generic
4
PA
ZOLEDRONIC ACID RECON SOLN 4 MG
zoledronic acid
BRAND
4
PA
ZOLEDRONIC ACID SOLUTION 4 MG/100ML
zoledronic acid
BRAND
4
PA
zoledronic acid solution 5 mg/100ml
generic
4
PA
ZOMETA SOLUTION 4 MG/100ML
zoledronic acid
BRAND
4
PA
ACTHAR HP GEL 80 UNIT/ML
corticotropin
BRAND
4
PA
HP ACTHAR GEL 80 UNIT/ML
corticotropin
BRAND
4
PA
BRAVELLE RECON SOLN 75 UNIT
urofollitropin purified
BRAND
2
PA
chorionic gonadotropin recon soln 10000 unit
generic
1
PA
clomiphene citrate tab 50 mg
generic
1
PA
FOLLISTIM AQ SOLUTION 150 UNT/0.5ML
follitropin beta
BRAND
4
PA
follitropin beta
BRAND
4
PA
follitropin beta
BRAND
4
PA
follitropin beta
BRAND
4
PA
follitropin beta
BRAND
4
PA
*Corticotropin**
*Fertility Regulators**
PAGE 140
PRODUCT DESCRIPTION
BRAND/GEN
TIER
GONAL-F RECON SOLN 1050 UNIT
follitropin alfa
BRAND
2
PA
GONAL-F RECON SOLN 450 UNIT
follitropin alfa
BRAND
2
PA
GONAL-F RFF PEN SOLUTION 300
UNIT/0.5ML
follitropin alfa
BRAND
2
PA
UNT/0.75ML
follitropin alfa
BRAND
2
PA
UNIT/1.5ML
follitropin alfa
BRAND
2
PA
GONAL-F RFF RECON SOLN 75 UNIT
follitropin alfa
BRAND
2
PA
LUVERIS RECON SOLN 75 UNIT
lutropin alfa
BRAND
2
PA
novarel recon soln 10000 unit
generic
1
PA
OVIDREL INJECTABLE 250 MCG/0.5ML
choriogonadotropin alfa
BRAND
4
PA
pregnyl recon soln 10000 unit
generic
1
PA
REPRONEX RECON SOLN 75 UNIT
menotropins
BRAND
2
PA
serophene tab 50 mg
generic
1
PA
CETROTIDE KIT 0.25 MG
cetrorelix acetate
BRAND
3
PA
CETROTIDE KIT 3 MG
cetrorelix acetate
BRAND
3
PA
GANIRELIX ACETATE SOLUTION 250
MCG/0.5ML
ganirelix acetate
BRAND
2
PA
SOMAVERT RECON SOLN 10 MG
pegvisomant
BRAND
4
PA
pegvisomant
BRAND
4
PA
pegvisomant
BRAND
4
PA
*GnRH/LHRH Antagonists**
*Growth Hormone Receptor Antagonists**
PAGE 141
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Growth Hormone Releasing Hormones (GHRH)**
EGRIFTA RECON SOLN 1 MG
tesamorelin acetate
BRAND
4
PA
EGRIFTA RECON SOLN 2 MG
tesamorelin acetate
BRAND
4
PA
GENOTROPIN MINIQUICK RECON SOLN 0.2
MG
somatropin
BRAND
4
PA
MG
somatropin
BRAND
4
PA
MG
somatropin
BRAND
4
PA
MG
somatropin
BRAND
4
PA
GENOTROPIN MINIQUICK RECON SOLN 1
MG
somatropin
BRAND
4
PA
MG
somatropin
BRAND
4
PA
MG
somatropin
BRAND
4
PA
MG
somatropin
BRAND
4
PA
MG
somatropin
BRAND
4
PA
GENOTROPIN MINIQUICK RECON SOLN 2
MG
somatropin
BRAND
4
PA
GENOTROPIN RECON SOLN 12 MG
somatropin
BRAND
4
PA
GENOTROPIN RECON SOLN 5 MG
somatropin
BRAND
4
PA
HUMATROPE RECON SOLN 12 MG
somatropin
BRAND
4
PA
*Growth Hormones**
PAGE 142
PRODUCT DESCRIPTION
BRAND/GEN
somatropin
BRAND
4
PA
somatropin
BRAND
4
PA
somatropin
BRAND
4
PA
NORDITROPIN FLEXPRO SOLUTION 10
MG/1.5ML
somatropin
BRAND
4
PA
MG/1.5ML
somatropin
BRAND
4
PA
MG/1.5ML
somatropin
BRAND
4
PA
NORDITROPIN NORDIFLEX PEN SOLUTION
10 MG/1.5ML
somatropin
BRAND
4
PA
15 MG/1.5ML
somatropin
BRAND
4
PA
30 MG/3ML
somatropin
BRAND
4
PA
5 MG/1.5ML
somatropin
BRAND
4
PA
NORDITROPIN SOLUTION 15 MG/1.5ML
somatropin
BRAND
4
PA
NORDITROPIN SOLUTION 5 MG/1.5ML
somatropin
BRAND
4
PA
NUTROPIN AQ NUSPIN 10 SOLUTION 10
MG/2ML
somatropin
BRAND
4
PA
MG/2ML
somatropin
BRAND
4
PA
MG/2ML
somatropin
BRAND
4
PA
NUTROPIN AQ PEN SOLUTION 10 MG/2ML
somatropin
BRAND
4
PA
NUTROPIN AQ PEN SOLUTION 20 MG/2ML
BRAND
4
PA
PAGE 143
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
somatropin
NUTROPIN AQ SOLUTION 10 MG/2ML
somatropin
BRAND
4
PA
NUTROPIN RECON SOLN 10 MG
somatropin
BRAND
4
PA
OMNITROPE RECON SOLN 5.8 MG
somatropin
BRAND
4
PA
OMNITROPE SOLUTION 10 MG/1.5ML
somatropin
BRAND
4
PA
OMNITROPE SOLUTION 5 MG/1.5ML
somatropin
BRAND
4
PA
SAIZEN CLICK.EASY RECON SOLN 8.8 MG
somatropin (non-refrigerated)
BRAND
4
PA
SAIZEN RECON SOLN 5 MG
BRAND
4
PA
SAIZEN RECON SOLN 8.8 MG
BRAND
4
PA
SEROSTIM RECON SOLN 4 MG
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
TEV-TROPIN RECON SOLN 5 MG
somatropin
BRAND
4
PA
ZORBTIVE RECON SOLN 8.8 MG
BRAND
4
PA
generic
0
BRAND
4
PA
*Hormone Receptor Modulators**
raloxifene hcl tab 60 mg
*Insulin-Like Growth Factors (Somatomedins)**
INCRELEX SOLUTION 40 MG/4ML
mecasermin
*LHRH/GnRH Agonist Analog Pituitary Suppressants**
LUPRON DEPOT-PED KIT 11.25 MG
leuprolide acetate (cpp)
BRAND
4
PA
LUPRON DEPOT-PED KIT 11.25 MG (PED)
leuprolide acetate (cpp) (3 month)
BRAND
4
PA
LUPRON DEPOT-PED KIT 15 MG
BRAND
4
PA
PAGE 144
PRODUCT DESCRIPTION
BRAND/GEN
TIER
LUPRON DEPOT-PED KIT 30 MG (PED)
leuprolide acetate (cpp) (3 month)
BRAND
4
PA
LUPRON DEPOT-PED KIT 7.5 MG
BRAND
4
PA
SUPPRELIN LA KIT 50 MG
histrelin acetate (cpp)
BRAND
4
PA
SYNAREL SOLUTION 2 MG/ML
nafarelin acetate
BRAND
4
PA
BUPHENYL TAB 500 MG
sodium phenylbutyrate
BRAND
4
calcitriol cap 0.25 mcg
generic
1
calcitriol cap 0.5 mcg
generic
1
doxercalciferol cap 0.5 mcg
generic
1
doxercalciferol cap 1 mcg
generic
1
doxercalciferol cap 2.5 mcg
generic
1
KUVAN PACKET 100 MG
sapropterin dihydrochloride
BRAND
4
PA
KUVAN TAB SOL 100 MG
sapropterin dihydrochloride
BRAND
4
PA
LUMIZYME RECON SOLN 50 MG
alglucosidase alfa
BRAND
4
PA
MYALEPT RECON SOLN 11.3 MG
metreleptin
BRAND
4
ORFADIN CAP 10 MG
nitisinone
BRAND
4
PA
ORFADIN CAP 2 MG
nitisinone
BRAND
4
PA
ORFADIN CAP 5 MG
nitisinone
BRAND
4
PA
paricalcitol cap 1 mcg
generic
3
generic
3
generic
3
RAVICTI LIQUID 1.1 GM/ML
glycerol phenylbutyrate
BRAND
4
sodium phenylbutyrate powder 3 gm/tsp
generic
4
VIMIZIM SOLUTION 5 MG/5ML
elosulfase alfa
BRAND
4
*Metabolic Modifiers**
PAGE 145
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Posterior Pituitary Hormones**
desmopressin ace rhinal tube solution 0.01 %
generic
1
MPL
3 / 30 days
desmopressin ace spray refrig solution 0.01 %
generic
1
MPL
3 / 30 days
desmopressin acetate spray solution 0.01 %
generic
1
MPL
3 / 30 days
desmopressin acetate tab 0.1 mg
generic
1
QL
90 / 30 days
desmopressin acetate tab 0.2 mg
generic
1
QL
90 / 30 days
minirin 0.1 mg/ml
generic
1
STIMATE SOLUTION 1.5 MG/ML
desmopressin acetate
BRAND
4
generic
1
octreotide acetate solution 100 mcg/ml
generic
4
PA
octreotide acetate solution 1000 mcg/5ml
generic
4
PA
generic
4
PA
generic
4
PA
generic
4
PA
generic
4
PA
SANDOSTATIN LAR DEPOT KIT 10 MG
octreotide acetate
BRAND
4
PA
octreotide acetate
BRAND
4
PA
octreotide acetate
BRAND
4
PA
SAMSCA TAB 15 MG
tolvaptan
BRAND
4
PA
SAMSCA TAB 30 MG
tolvaptan
BRAND
4
PA
PA
*Prolactin Inhibitors**
cabergoline tab 0.5 mg
*Somatostatic Agents**
*Vasopressin Receptor Antagonists**
*ESTROGENS*
*Estrogen Combinations**
PAGE 146
PRODUCT DESCRIPTION
BRAND/GEN
TIER
CLIMARA PRO PATCH WK 0.045-0.015
MG/DAY
estradiol-levonorgestrel
BRAND
3
covaryx hs tab 0.625-1.25 mg
generic
1
covaryx tab 1.25-2.5 mg
generic
1
eemt hs tab 0.625-1.25 mg
generic
1
eemt tab 1.25-2.5 mg
generic
1
essian h.s. tab 0.625-1.25 mg
generic
1
essian tab 1.25-2.5 mg
generic
1
est estrogens-methyltest ds tab 1.25-2.5 mg
generic
1
est estrogens-methyltest hs tab 0.625-1.25 mg
generic
1
est estrogens-methyltest tab 1.25-2.5 mg
generic
1
PREMPHASE TAB 0.625-5 MG
conjugated estrogens-medroxyprogesterone
acetate
BRAND
2
PREMPRO TAB 0.3-1.5 MG
acetate
BRAND
2
acetate
BRAND
2
acetate
BRAND
2
PREMPRO TAB 0.625-5 MG
acetate
BRAND
2
CENESTIN TAB 0.3 MG
estrogens, conjugated synthetic a
BRAND
3
CENESTIN TAB 0.45 MG
BRAND
3
BRAND
3
CENESTIN TAB 0.9 MG
BRAND
3
BRAND
3
DELESTROGEN OIL 10 MG/ML
BRAND
2
*Estrogens**
PAGE 147
PRODUCT DESCRIPTION
BRAND/GEN
TIER
estradiol valerate
DEPO-ESTRADIOL OIL 5 MG/ML
estradiol cypionate
BRAND
2
DIVIGEL GEL 0.25 MG/0.25GM
estradiol
BRAND
2
DIVIGEL GEL 0.5 MG/0.5GM
estradiol
BRAND
2
DIVIGEL GEL 1 MG/GM
estradiol
BRAND
2
ELESTRIN GEL 0.52 MG/0.87 GM (0.06%)
estradiol
BRAND
2
ENJUVIA TAB 0.3 MG
estrogens, conjugated synthetic b
BRAND
3
ENJUVIA TAB 0.45 MG
BRAND
3
ENJUVIA TAB 0.625 MG
BRAND
3
ENJUVIA TAB 0.9 MG
BRAND
3
ENJUVIA TAB 1.25 MG
BRAND
3
estradiol patch wk 0.025 mg/24hr
generic
1
generic
1
generic
1
generic
1
generic
1
generic
1
estradiol tab 0.5 mg
generic
1
estradiol tab 1 mg
generic
1
estradiol tab 2 mg
generic
1
ESTRASORB EMULSION 4.35 MG/1.74GM
estradiol
BRAND
2
ESTROGEL GEL 0.75 MG/1.25 GM (0.06%)
estradiol
BRAND
2
estropipate tab 0.75 mg
generic
1
estropipate tab 1.5 mg
generic
1
estropipate tab 3 mg
generic
1
PAGE 148
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ESTROPIPATE TAB 3 MG
estropipate
BRAND
2
EVAMIST SOLUTION 1.53 MG/SPRAY
estradiol
BRAND
2
MENEST TAB 0.3 MG
esterified estrogens
BRAND
3
MENEST TAB 0.625 MG
BRAND
3
MENEST TAB 1.25 MG
BRAND
3
MENEST TAB 2.5 MG
BRAND
3
MENOSTAR PATCH WK 14 MCG/24HR
estradiol
BRAND
2
PREMARIN RECON SOLN 25 MG
estrogens, conjugated
BRAND
2
PREMARIN TAB 0.3 MG
BRAND
2
PREMARIN TAB 0.45 MG
BRAND
2
BRAND
2
PREMARIN TAB 0.9 MG
BRAND
2
BRAND
2
VIVELLE-DOT PATCH TW 0.025 MG/24HR
estradiol
BRAND
2
estradiol
BRAND
2
estradiol
BRAND
2
estradiol
BRAND
2
estradiol
BRAND
2
BRAND
2
*FLUOROQUINOLONES*
*Fluoroquinolones**
AVELOX SOLUTION 400 MG/250ML
moxifloxacin hcl in sodium chloride
PAGE 149
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ciprofloxacin hcl tab 100 mg
generic
1
generic
1
generic
1
generic
1
ciprofloxacin in d5w solution 200 mg/100ml
generic
1
PA
ciprofloxacin in d5w solution 400 mg/200ml
generic
1
PA
ciprofloxacin solution 1200 mg/120ml
generic
1
PA
generic
1
PA
generic
1
PA
ciprofloxacin-ciproflox hcl er tab er 24h 1000
mg
generic
1
ciprofloxacin-ciproflox hcl er tab er 24h 500 mg
generic
1
FACTIVE TAB 320 MG
gemifloxacin mesylate
BRAND
2
levofloxacin in d5w solution 250 mg/50ml
generic
1
PA
generic
1
PA
generic
1
PA
levofloxacin solution 25 mg/ml
generic
1
PA
levofloxacin tab 250 mg
generic
1
generic
1
generic
1
moxifloxacin hcl tab 400 mg
generic
1
NOROXIN TAB 400 MG
norfloxacin
BRAND
3
ofloxacin tab 200 mg
generic
1
generic
1
generic
1
OFLOXACIN TAB 400 MG
ofloxacin
BRAND
2
generic
1
*GASTROINTESTINAL AGENTS - MISC.*
*Gallstone Solubilizing Agents**
ursodiol cap 300 mg
PAGE 150
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ursodiol tab 250 mg
generic
1
ursodiol tab 500 mg
generic
1
AMITIZA CAP 24 MCG
lubiprostone
BRAND
2
AMITIZA CAP 8 MCG
lubiprostone
BRAND
2
metoclopramide hcl solution 1 mg/ml
generic
1
metoclopramide hcl solution 10 mg/10ml
generic
1
metoclopramide hcl solution 5 mg/5ml
generic
1
metoclopramide hcl solution 5 mg/ml
generic
1
metoclopramide hcl tab 10 mg
generic
1
metoclopramide hcl tab 5 mg
generic
1
APRISO CAP ER 24H 0.375 GM
mesalamine
BRAND
2
ASACOL HD TAB DR 800 MG
mesalamine
BRAND
3
ASACOL TAB DR 400 MG
mesalamine
BRAND
2
balsalazide disodium cap 750 mg
generic
1
CANASA SUPPOS 1000 MG
mesalamine
BRAND
3
CIMZIA KIT 2 X 200 MG
certolizumab pegol
BRAND
4
PA
CIMZIA PREFILLED KIT 2 X 200 MG/ML
certolizumab pegol
BRAND
4
PA
CIMZIA STARTER KIT KIT 6 X 200 MG/ML
certolizumab pegol
BRAND
4
PA
DELZICOL CAP DR 400 MG
mesalamine
BRAND
3
DIPENTUM CAP 250 MG
olsalazine sodium
BRAND
3
LIALDA TAB DR 1.2 GM
mesalamine
BRAND
3
mesalamine enema 4 gm
generic
1
*Gastrointestinal Chloride Channel Activators**
*Gastrointestinal Stimulants**
PA
*Inflammatory Bowel Agents**
PAGE 151
PRODUCT DESCRIPTION
BRAND/GEN
TIER
PENTASA CAP ER 250 MG
mesalamine
BRAND
3
PENTASA CAP ER 500 MG
mesalamine
BRAND
3
REMICADE RECON SOLN 100 MG
infliximab
BRAND
4
SFROWASA ENEMA 4 GM/60ML
mesalamine
BRAND
3
sulfasalazine tab 500 mg
generic
1
sulfasalazine tab dr 500 mg
generic
1
sulfazine ec tab dr 500 mg
generic
1
sulfazine tab 500 mg
generic
1
enulose solution 10 gm/15ml
generic
1
generlac solution 10 gm/15ml
generic
1
lactulose encephalopathy solution 10 gm/15ml
generic
1
LOTRONEX TAB 0.5 MG
alosetron hcl
BRAND
4
PA
LOTRONEX TAB 1 MG
alosetron hcl
BRAND
4
PA
ENTEREG CAP 12 MG
alvimopan
BRAND
3
PA
RELISTOR SOLUTION 12 MG/0.6ML
methylnaltrexone bromide
BRAND
3
PA
RELISTOR SOLUTION 8 MG/0.4ML
methylnaltrexone bromide
BRAND
3
PA
calcium acetate (phos binder) tab 667 mg
generic
1
FOSRENOL CHEW TAB 1000 MG
lanthanum carbonate
BRAND
3
ST
lanthanum carbonate
BRAND
3
ST
lanthanum carbonate
BRAND
3
ST
PHOSLYRA SOLUTION 667 MG/5ML
BRAND
3
PA
*Intestinal Acidifiers**
*Irritable Bowel Syndrome (IBS) Agents**
*Peripheral Opioid Receptor Antagonists**
*Phosphate Binder Agents**
PAGE 152
PRODUCT DESCRIPTION
BRAND/GEN
TIER
calcium acetate (phosphate binder)
RENAGEL TAB 400 MG
sevelamer hcl
BRAND
2
RENAGEL TAB 800 MG
sevelamer hcl
BRAND
2
RENVELA PACKET 0.8 GM
sevelamer carbonate
BRAND
3
RENVELA PACKET 2.4 GM
sevelamer carbonate
BRAND
3
RENVELA TAB 800 MG
sevelamer carbonate
BRAND
3
SEVELAMER CARBONATE TAB 800 MG
sevelamer carbonate
BRAND
3
BRAND
4
cytra k crystals packet 3300-1002 mg
generic
1
potassium citrate er tab er 10 meq (1080 mg)
generic
2
POTASSIUM CITRATE ER TAB ER 10 MEQ
(1080 MG)
potassium citrate (alkalinizer)
BRAND
2
generic
1
generic
2
taron-crystals packet 3300-1002 mg
generic
1
PROCYSBI CAP DR 25 MG
cysteamine bitartrate
BRAND
4
PROCYSBI CAP DR 75 MG
cysteamine bitartrate
BRAND
4
acetic acid solution 0.25 %
generic
1
aminoacetic acid solution 1.5 %
generic
1
glycine solution 1.5 %
generic
1
glycine urologic solution 1.5 %
generic
1
*Short Bowel Syndrome (SBS) Agents**
GATTEX KIT 5 MG
teduglutide (rdna)
PA
*GENITOURINARY AGENTS - MISCELLANEOUS*
*Alkalinizers**
*Cystinosis Agents**
*Genitourinary Irrigants**
1
PAGE 153
PRODUCT DESCRIPTION
BRAND/GEN
sodium chloride solution 0.9 %
generic
TIER
*Interstitial Cystitis Agents**
ELMIRON CAP 100 MG
pentosan polysulfate sodium
BRAND
3
alfuzosin hcl er tab er 24h 10 mg
generic
1
AVODART CAP 0.5 MG
dutasteride
BRAND
3
finasteride tab 5 mg
generic
1
RAPAFLO CAP 4 MG
silodosin
BRAND
2
ST
RAPAFLO CAP 8 MG
silodosin
BRAND
2
ST
tamsulosin hcl cap 0.4 mg
generic
1
phenazo tab 200 mg
generic
1
phenazopyridine hcl tab 100 mg
generic
1
phenazopyridine hcl tab 200 mg
generic
1
generic
1
allopurinol tab 100 mg
generic
1
allopurinol tab 300 mg
generic
1
colchicine tab 0.6 mg
generic
1
QL
120 / 30 days
COLCRYS TAB 0.6 MG
colchicine
BRAND
2
QL
120 / 30 days
KRYSTEXXA SOLUTION 8 MG/ML
pegloticase
BRAND
4
PA
ULORIC TAB 40 MG
febuxostat
BRAND
3
ST
ULORIC TAB 80 MG
febuxostat
BRAND
3
ST
*Prostatic Hypertrophy Agents**
QL
30 / 30 days
QL
30 / 30 days
ST
*Urinary Analgesics**
*GOUT AGENTS*
*Gout Agent Combinations**
colchicine-probenecid tab 0.5-500 mg
*Gout Agents**
*Uricosurics**
PAGE 154
PRODUCT DESCRIPTION
BRAND/GEN
TIER
probenecid tab 500 mg
generic
1
ADVATE RECON SOLN 1000 UNIT
antihemophilic factor rahf-pfm
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
ALPHANATE/VWF COMPLEX/HUMAN
RECON SOLN 1000 UNIT
antihemophilic factor/von willebrand factor
complex (human)
BRAND
4
PA
RECON SOLN 1500 UNIT
complex (human)
BRAND
4
PA
RECON SOLN 250 UNIT
complex (human)
BRAND
4
PA
RECON SOLN 500 UNIT
complex (human)
BRAND
4
PA
ALPHANINE SD RECON SOLN 1000 UNIT
coagulation factor ix
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
ALPROLIX RECON SOLN 1000 UNIT
coagulation factor ix (recomb) fc fusion protein
(rfixfc)
BRAND
4
*HEMATOLOGICAL AGENTS - MISC.*
*Antihemophilic Products**
PAGE 155
PRODUCT DESCRIPTION
BRAND/GEN
(rfixfc)
BRAND
4
(rfixfc)
BRAND
4
(rfixfc)
BRAND
4
BEBULIN RECON SOLN 200-1200 UNIT
factor ix complex
BRAND
4
PA
BEBULIN VH RECON SOLN 200-1200 UNIT
factor ix complex
BRAND
4
PA
BENEFIX RECON SOLN 1000 UNIT
coagulation factor ix (recombinant)
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
CORIFACT KIT 1000-1600 UNIT
factor xiii concentrate (human)
BRAND
2
PA
FEIBA NF RECON SOLN
antiinhibitor coagulant complex
BRAND
4
PA
FEIBA VH IMMUNO RECON SOLN
antiinhibitor coagulant complex
BRAND
4
PA
HELIXATE FS KIT 1000 UNIT
antihemophilic factor (recombinant)
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
HEMOFIL M RECON SOLN 1000 UNIT
antihemophilic factor (human)
BRAND
4
PA
PAGE 156
TIER
PRODUCT DESCRIPTION
BRAND/GEN
HEMOFIL M RECON SOLN 1501-2000 UNIT
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
HUMATE-P RECON SOLN 1000-2400 UNIT
complex (human)
BRAND
4
PA
complex (human)
BRAND
4
PA
complex (human)
BRAND
4
PA
KOATE-DVI RECON SOLN 1000 UNIT
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
KOGENATE FS BIO-SET KIT 1000 UNIT
BRAND
4
BRAND
4
BRAND
4
BRAND
4
BRAND
4
PAGE 157
TIER
PRODUCT DESCRIPTION
BRAND/GEN
KOGENATE FS KIT 1000 UNIT
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
MONOCLATE-P KIT 1000 UNIT
BRAND
4
MONOCLATE-P KIT 1500 UNIT
BRAND
4
MONONINE RECON SOLN 1000 UNIT
BRAND
4
PA
NOVOSEVEN RT RECON SOLN 1 MG
coagulation factor viia (recombinant)
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
PROFILNINE SD RECON SOLN 1000 UNIT
factor ix complex
BRAND
4
PA
factor ix complex
BRAND
4
PA
factor ix complex
BRAND
4
PA
RECOMBINATE RECON SOLN 1241-1800
UNIT
BRAND
4
PA
UNIT
BRAND
4
PA
RECOMBINATE RECON SOLN 220-400 UNIT
BRAND
4
PA
RECOMBINATE RECON SOLN 401-800 UNIT
BRAND
4
PA
BRAND
4
PA
PAGE 158
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
UNIT
RIASTAP RECON SOLN
fibrinogen concentrate (human)
BRAND
4
RIXUBIS RECON SOLN 1000 UNIT
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
TRETTEN RECON SOLN 2000-3125 UNIT
coagulation factor xiii a-subunit (recombinant)
BRAND
4
WILATE RECON SOLN 1000-1000 UNIT
complex (human)
BRAND
4
PA
complex (human)
BRAND
2
PA
complex (human)
BRAND
4
PA
complex (human)
BRAND
2
PA
XYNTHA KIT 1000 UNIT
plasma/alblumin free
BRAND
4
PA
XYNTHA KIT 2000 UNIT
BRAND
4
PA
XYNTHA KIT 250 UNIT
BRAND
4
PA
XYNTHA KIT 500 UNIT
BRAND
4
PA
XYNTHA SOLOFUSE KIT 1000 UNIT
BRAND
4
PA
PAGE 159
PRODUCT DESCRIPTION
BRAND/GEN
TIER
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BERINERT KIT 500 UNIT
c1 esterase inhibitor (human)
BRAND
4
CINRYZE RECON SOLN 500 UNIT
c1 esterase inhibitor (human)
BRAND
4
PA
SOLIRIS SOLUTION 10 MG/ML
eculizumab
BRAND
4
PA
generic
1
CEPROTIN RECON SOLN 1000 UNIT
protein c concentrate (human)
BRAND
4
PA
CEPROTIN RECON SOLN 500 UNIT
protein c concentrate (human)
BRAND
4
PA
BRAND
4
PA
ATRYN RECON SOLN 1750 UNIT
antithrombin (human) (recombinant)
BRAND
2
PA
THROMBATE III RECON SOLN 1000 UNIT
antithrombin iii (human)
BRAND
2
PA
THROMBATE III RECON SOLN 500 UNIT
antithrombin iii (human)
BRAND
4
PA
BRAND
3
*Complement Inhibitors**
*Hematorheologic Agents**
pentoxifylline er tab er 400 mg
*Human Protein C**
*Plasma Kallikrein Inhibitors**
KALBITOR SOLUTION 10 MG/ML
ecallantide
*Plasma Proteins**
*Platelet Aggregation Inhibitors**
AGGRENOX CAP ER 12H 25-200 MG
aspirin-dipyridamole
PAGE 160
PRODUCT DESCRIPTION
BRAND/GEN
TIER
anagrelide hcl cap 0.5 mg
generic
1
anagrelide hcl cap 1 mg
generic
1
cilostazol tab 100 mg
generic
1
cilostazol tab 50 mg
generic
1
clopidogrel bisulfate tab 75 mg
generic
1
dipyridamole tab 25 mg
generic
1
generic
1
generic
1
EFFIENT TAB 10 MG
prasugrel hcl
BRAND
3
EFFIENT TAB 5 MG
prasugrel hcl
BRAND
3
REOPRO SOLUTION 2 MG/ML
abciximab
BRAND
4
ticlopidine hcl tab 250 mg
generic
1
CEREDASE SOLUTION 80 UNIT/ML
alglucerase
BRAND
4
PA
CEREZYME RECON SOLN 200 UNIT
imiglucerase
BRAND
4
PA
CEREZYME RECON SOLN 400 UNIT
imiglucerase
BRAND
4
PA
ELELYSO RECON SOLN 200 UNIT
taliglucerase alfa
BRAND
4
VPRIV RECON SOLN 400 UNIT
velaglucerase alfa
BRAND
4
PA
DROXIA CAP 200 MG
hydroxyurea (sickle cell anemia)
BRAND
4
PA
DROXIA CAP 300 MG
BRAND
4
PA
DROXIA CAP 400 MG
BRAND
4
PA
generic
1
PA
*HEMATOPOIETIC AGENTS*
*Agents for Gaucher Disease**
*Agents for Sickle Cell Anemia**
*Cobalamins**
cyanocobalamin solution 1000 mcg/ml
PAGE 161
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Folic Acid/Folates**
DULEEK-DP TAB 15 MG
folic acid
BRAND
DULEEK-DP TAB 7.5 MG
folic acid
BRAND
folic acid 1 mg
generic
0
folic acid powder
generic
0
folic acid solution 5 mg/ml
folic acid tab 1 mg
generic
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
0
0
0
generic
0
ARANESP (ALBUMIN FREE) SOLUTION 100
MCG/0.5ML
darbepoetin alfa-polysorbate 80
BRAND
4
PA
MCG/ML
BRAND
4
PA
MCG/0.3ML
BRAND
4
PA
MCG/0.75ML
BRAND
4
PA
MCG/0.4ML
BRAND
4
PA
MCG/ML
BRAND
4
PA
MCG/0.42ML
BRAND
4
PA
MCG/ML
BRAND
4
PA
MCG/0.6ML
BRAND
4
PA
*Hematopoietic Growth Factors**
PAGE 162
PRODUCT DESCRIPTION
BRAND/GEN
MCG/ML
BRAND
4
PA
MCG/0.4ML
BRAND
4
PA
MCG/ML
BRAND
4
PA
MCG/ML
BRAND
4
PA
MCG/0.3ML
BRAND
4
PA
MCG/ML
BRAND
4
PA
EPOGEN SOLUTION 10000 UNIT/ML
epoetin alfa
BRAND
4
PA
epoetin alfa
BRAND
4
PA
epoetin alfa
BRAND
4
PA
epoetin alfa
BRAND
4
PA
epoetin alfa
BRAND
4
PA
GRANIX SOLN PRSYR 300 MCG/0.5ML
tbo-filgrastim
BRAND
2
PA
GRANIX SOLN PRSYR 480 MCG/0.8ML
tbo-filgrastim
BRAND
2
PA
LEUKINE RECON SOLN 250 MCG
sargramostim
BRAND
4
PA
LEUKINE SOLUTION 500 MCG/ML
sargramostim
BRAND
4
PA
NEULASTA SOLUTION 6 MG/0.6ML
pegfilgrastim
BRAND
4
PA
NEUMEGA RECON SOLN 5 MG
oprelvekin
BRAND
4
PA
NEUPOGEN SOLUTION 300 MCG/0.5ML
filgrastim
BRAND
4
PA
PAGE 163
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
NEUPOGEN SOLUTION 300 MCG/ML
filgrastim
BRAND
4
PA
filgrastim
BRAND
4
PA
filgrastim
BRAND
4
PA
NPLATE RECON SOLN 250 MCG
romiplostim
BRAND
4
PA
NPLATE RECON SOLN 500 MCG
romiplostim
BRAND
4
PA
PROCRIT SOLUTION 10000 UNIT/ML
epoetin alfa
BRAND
4
PA
epoetin alfa
BRAND
4
PA
epoetin alfa
BRAND
4
PA
epoetin alfa
BRAND
4
PA
epoetin alfa
BRAND
4
PA
epoetin alfa
BRAND
4
PA
PROMACTA TAB 12.5 MG
eltrombopag olamine
BRAND
4
PA
PROMACTA TAB 25 MG
eltrombopag olamine
BRAND
4
PA
PROMACTA TAB 50 MG
eltrombopag olamine
BRAND
4
PA
PROMACTA TAB 75 MG
eltrombopag olamine
BRAND
4
PA
iferex 150 forte cap 150-25-1 mg-mcg-mg
generic
1
myferon 150 forte cap 150-25-1 mg-mcg-mg
generic
1
poly-iron 150 forte cap 150-25-1 mg-mcg-mg
generic
1
polysaccharide iron forte cap 150-25-1 mgmcg-mg
generic
1
generic
0
*Hematopoietic Mixtures**
*Iron**
dexferrum solution 50 mg/ml
AL
Up to 1 yrs old
0
PAGE 164
PRODUCT DESCRIPTION
BRAND/GEN
FERAHEME SOLUTION 510 MG/17ML
ferumoxytol
BRAND
ferrous sulfate granules
generic
ferrous sulfate powder
TIER
AL
Up to 1 yrs old
0
AL
Up to 1 yrs old
generic
0
AL
Up to 1 yrs old
infed solution 50 mg/ml
generic
0
AL
Up to 1 yrs old
INJECTAFER SOLUTION 750 MG/15ML
ferric carboxymaltose
BRAND
0
AL
Up to 1 yrs old
na ferric gluc cplx in sucrose solution 12.5
mg/ml
generic
0
AL
Up to 1 yrs old
nulecit solution 12.5 mg/ml
generic
0
AL
Up to 1 yrs old
VENOFER SOLUTION 20 MG/ML
iron sucrose
BRAND
0
AL
Up to 1 yrs old
BRAND
4
PA
tranexamic acid solution 100 mg/ml
generic
1
PA
tranexamic acid tab 650 mg
generic
1
phenobarbital elixir 20 mg/5ml
generic
1
phenobarbital solution 20 mg/5ml
generic
1
phenobarbital tab 100 mg
generic
1
PHENOBARBITAL TAB 100 MG
phenobarbital
BRAND
2
generic
1
phenobarbital
BRAND
2
phenobarbital tab 16.2 mg
generic
1
generic
1
phenobarbital
BRAND
2
generic
1
*Stem Cell Mobilizers**
MOZOBIL SOLUTION 24 MG/1.2ML
plerixafor
*HEMOSTATICS*
*Hemostatics - Systemic**
*HYPNOTICS*
*Barbiturate Hypnotics**
PAGE 165
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
1
phenobarbital
BRAND
2
generic
1
generic
1
generic
3
*Non-Barbiturate Hypnotics**
QL
eszopiclone tab 1 mg
30 / 30 days
ST
QL
generic
30 / 30 days
3
ST
QL
generic
30 / 30 days
3
ST
QL
30 / 30 days
LUNESTA TAB 2 MG
eszopiclone
BRAND
LUNESTA TAB 3 MG
eszopiclone
BRAND
zaleplon cap 10 mg
generic
1
QL
30 / 30 days
zaleplon cap 5 mg
generic
1
QL
30 / 30 days
zolpidem tartrate er tab er 12.5 mg
generic
1
QL
30 / 30 days
zolpidem tartrate er tab er 6.25 mg
generic
1
QL
30 / 30 days
zolpidem tartrate tab 10 mg
generic
1
QL
30 / 30 days
zolpidem tartrate tab 5 mg
generic
1
QL
30 / 30 days
QL
BRAND
30 / 30 days
3
3
ST
QL
30 / 30 days
3
ST
*Selective Melatonin Receptor Agonists**
ROZEREM TAB 8 MG
ramelteon
ST
*LAXATIVES*
*Laxative Combinations**
COLYTE WITH FLAVOR PACKS RECON
SOLN 227.1 GM
peg 3350-kcl-sod bicarb-sod chloride-sod
sulfate
BRAND
0
gavilyte-c recon soln 240 gm
generic
0
PAGE 166
AL
55 to 75 yrs old
PRODUCT DESCRIPTION
BRAND/GEN
TIER
gavilyte-g recon soln 236 gm
generic
0
gavilyte-n with flavor pack recon soln 420 gm
generic
0
GOLYTELY RECON SOLN 227.1 GM
peg 3350-kcl-sod bicarb-sod chloride-sod
sulfate
BRAND
0
AL
55 to 75 yrs old
HALFLYTELY WITH FLAVOR PACKS KIT 5210 MG-GM
bisacodyl-peg 3350-pot chloride-sod bicarb-sod
chloride
BRAND
0
AL
55 to 75 yrs old
MOVIPREP RECON SOLN 100 GM
peg 3350-kcl-nacl-na sulfate-na ascorbateascorbic acid
BRAND
0
AL
55 to 75 yrs old
peg 3350-kcl-na bicarb-nacl recon soln 420 gm
generic
0
peg 3350/electrolytes recon soln 240 gm
generic
0
peg-3350/electrolytes recon soln 236 gm
generic
0
SUCLEAR KIT
na sulfate-k sulfate-mg sulfate & peg3350-naclna bicarb-kcl
BRAND
0
AL
55 to 75 yrs old
SUPREP BOWEL PREP SOLUTION
sodium sulfate-potassium sulfate-magnesium
sulfate
BRAND
0
AL
55 to 75 yrs old
trilyte recon soln 420 gm
generic
0
constulose solution 10 gm/15ml
generic
1
lactulose solution 10 gm/15ml
generic
1
lactulose solution 20 gm/30ml
generic
1
pegylax powder
generic
3
polyethylene glycol 3350 packet
generic
1
polyethylene glycol 3350 powder
generic
3
BRAND
2
lidocaine-epinephrine solution 0.5 %-1:200000
generic
1
PA
lidocaine-epinephrine solution 1 %-1:100000
generic
1
PA
*Laxatives - Miscellaneous**
*Saline Laxatives**
OSMOPREP TAB 1.102-0.398 GM
sodium phosphate monobasic-sodium
phosphate dibasic
*LOCAL ANESTHETICS-Parenteral*
*Local Anesthetic Combinations**
PAGE 167
PRODUCT DESCRIPTION
BRAND/GEN
TIER
lidocaine-epinephrine solution 1.5 %-1:200000
generic
1
PA
generic
1
PA
generic
1
PA
XYLOCAINE-MPF/EPINEPHRINE SOLUTION
1 %-1:200000
lidocaine w/ epinephrine
BRAND
3
PA
lidocaine hcl (cardiac) solution 20 mg/ml
generic
1
PA
lidocaine hcl (pf) solution 0.5 %
generic
1
PA
lidocaine hcl (pf) solution 1 %
generic
1
PA
lidocaine hcl (pf) solution 2 %
generic
1
PA
lidocaine hcl solution 0.5 %
generic
1
PA
generic
1
PA
lidocaine hcl solution 1.5 %
generic
1
PA
generic
1
PA
generic
1
PA
azithromycin hydrogencitrate recon soln 2.5 gm
generic
1
PA
azithromycin packet 1 gm
generic
1
azithromycin recon soln 500 mg
generic
1
azithromycin recon susp 100 mg/5ml
generic
1
azithromycin recon susp 200 mg/5ml
generic
1
azithromycin tab 250 mg
generic
1
generic
1
generic
1
zithromax packet 1 gm
generic
1
clarithromycin er tab er 24h 500 mg
generic
1
clarithromycin recon susp 125 mg/5ml
generic
1
*Local Anesthetics - Amides**
*MACROLIDES*
*Azithromycin**
*Clarithromycin**
PAGE 168
PRODUCT DESCRIPTION
BRAND/GEN
TIER
clarithromycin recon susp 250 mg/5ml
generic
1
clarithromycin tab 250 mg
generic
1
clarithromycin tab 500 mg
generic
1
E.E.S. 400 TAB 400 MG
erythromycin ethylsuccinate
BRAND
2
e.e.s. 400 tab 400 mg
generic
1
e.e.s. granules recon susp 200 mg/5ml
generic
3
ERY-TAB TAB DR 250 MG
erythromycin base
BRAND
3
erythromycin base
BRAND
3
erythromycin base
BRAND
3
eryped 200 recon susp 200 mg/5ml
generic
3
ERYPED 400 RECON SUSP 400 MG/5ML
BRAND
3
ERYTHROCIN LACTOBIONATE RECON
SOLN 1000 MG
erythromycin lactobionate
BRAND
2
PA
ERYTHROCIN LACTOBIONATE RECON
SOLN 500 MG
erythromycin lactobionate
BRAND
2
PA
ERYTHROCIN STEARATE TAB 250 MG
erythromycin stearate
BRAND
2
ERYTHROMYCIN BASE CP DR PART 250
MG
erythromycin base
BRAND
2
erythromycin base tab 250 mg
generic
1
ERYTHROMYCIN BASE TAB 250 MG
erythromycin base
BRAND
2
erythromycin base tab 500 mg
generic
1
ERYTHROMYCIN BASE TAB 500 MG
erythromycin base
BRAND
2
erythromycin ethylsuccinate tab 400 mg
generic
1
ERYTHROMYCIN ETHYLSUCCINATE TAB
400 MG
BRAND
2
ERYTHROMYCIN STEARATE TAB 250 MG
BRAND
2
*Erythromycins**
PAGE 169
PRODUCT DESCRIPTION
BRAND/GEN
TIER
erythromycin stearate
PCE TAB DR 333 MG
erythromycin base (coated)
BRAND
3
PCE TAB DR 500 MG
erythromycin base (coated)
BRAND
3
BRAND
3
PA
FEMCAP DEVICE 22 MM
cervical caps
BRAND
0
GL
Female
FEMCAP DEVICE 26 MM
cervical caps
BRAND
0
GL
Female
FEMCAP DEVICE 30 MM
cervical caps
BRAND
0
GL
Female
OMNIFLEX DIAPHRAGM DIAPHRAGM
diaphragms
BRAND
0
GL
Female
ORTHO DIAPHRAGM ALL-FLEX
DIAPHRAGM 65 MM
diaphragm arc-spring
BRAND
0
GL
Female
DIAPHRAGM 70 MM
BRAND
0
GL
Female
DIAPHRAGM 75 MM
BRAND
0
GL
Female
DIAPHRAGM 80 MM
BRAND
0
GL
Female
PRENTIF FITTING SET MISC
cervical caps
BRAND
0
GL
Female
WIDE-SEAL DIAPHRAGM 60 DIAPHRAGM 2
%
diaphragm wide seal
BRAND
0
GL
Female
%
diaphragm wide seal
BRAND
0
GL
Female
%
diaphragm wide seal
BRAND
0
GL
Female
*Fidaxomicin**
DIFICID TAB 200 MG
fidaxomicin
*MEDICAL DEVICES*
*Contraceptives**
PAGE 170
PRODUCT DESCRIPTION
BRAND/GEN
TIER
%
diaphragm wide seal
BRAND
0
GL
Female
%
diaphragm wide seal
BRAND
0
GL
Female
%
diaphragm wide seal
BRAND
0
GL
Female
%
diaphragm wide seal
BRAND
0
GL
Female
%
diaphragm wide seal
BRAND
0
GL
Female
truecontrol glucose cont lev 0 liquid
generic
2
C
Copayment may vary
based on plan
truecontrol glucose cont lev 1 liquid
generic
2
C
Copayment may vary
based on plan
trueplus lancets 26g misc
generic
2
C
Copayment may vary
based on plan
generic
2
C
Copayment may vary
based on plan
generic
2
C
Copayment may vary
based on plan
generic
2
C
Copayment may vary
based on plan
trueplus safety lancets 28g misc
generic
2
C
Copayment may vary
based on plan
truetest control level 1 liquid
generic
2
C
Copayment may vary
based on plan
generic
2
C
Copayment may vary
based on plan
generic
2
C
Copayment may vary
based on plan
TRUETRACK BLOOD GLUCOSE DEVICE
blood glucose monitoring supplies
BRAND
2
C
Copayment may vary
based on plan
truetrack glucose control liquid
generic
2
C
Copayment may vary
based on plan
TRUETRACK GLUCOSE CONTROL LIQUID
HIGH
blood glucose calibration
BRAND
2
C
Copayment may vary
based on plan
*Diabetic Supplies**
PAGE 171
PRODUCT DESCRIPTION
BRAND/GEN
TIER
TRUETRACK GLUCOSE CONTROL LIQUID
LOW
blood glucose calibration
BRAND
2
CAFERGOT TAB 1-100 MG
ergotamine w/ caffeine
BRAND
3
epidrin cap 325-65-100 mg
generic
1
ergotamine-caffeine tab 1-100 mg
generic
3
isometheptene-apap-dichloral cap 65-325-100
mg
generic
1
ISOMETHEPTENE-CAFFEINE-APAP TAB
130-20-500 MG
isometheptene-caffeine-acetaminophen
BRAND
3
MIGERGOT SUPPOS 2-100 MG
ergotamine w/ caffeine
BRAND
3
migragesic ida cap 325-65-100 mg
generic
nodolor cap 325-65-100 mg
C
Copayment may vary
based on plan
*MIGRAINE PRODUCTS*
*Migraine Combinations**
QL
4 / day
QL
4 / day
1
QL
4 / day
generic
1
QL
4 / day
dihydroergotamine mesylate solution 1 mg/ml
generic
3
PA
dihydroergotamine mesylate solution 4 mg/ml
generic
3
QL
8 / 30 days
migranal solution 4 mg/ml
generic
3
QL
8 / 30 days
ALSUMA SOLN A-INJ 6 MG/0.5ML
sumatriptan succinate
BRAND
2
QL
4 / 30 days
AXERT TAB 12.5 MG
almotriptan malate
BRAND
3
QL
6 / 30 days
AXERT TAB 6.25 MG
almotriptan malate
BRAND
3
QL
6 / 30 days
FROVA TAB 2.5 MG
frovatriptan succinate
BRAND
3
QL
6 / 30 days
naratriptan hcl tab 1 mg
generic
1
QL
9 / 30 days
naratriptan hcl tab 2.5 mg
generic
1
QL
9 / 30 days
RELPAX TAB 20 MG
eletriptan hydrobromide
BRAND
3
QL
6 / 30 days
*Migraine Products**
*Serotonin Agonists**
PAGE 172
PRODUCT DESCRIPTION
BRAND/GEN
RELPAX TAB 40 MG
eletriptan hydrobromide
BRAND
3
QL
6 / 30 days
rizatriptan benzoate tab 10 mg
generic
1
QL
9 / 30 days
rizatriptan benzoate tab 5 mg
generic
1
QL
9 / 30 days
rizatriptan benzoate tab disp 10 mg
generic
1
QL
9 / 30 days
rizatriptan benzoate tab disp 5 mg
generic
1
QL
9 / 30 days
sumatriptan solution 20 mg/act
generic
1
QL
6 / 30 days
sumatriptan solution 5 mg/act
generic
1
QL
6 / 30 days
sumatriptan succinate refill soln cart 4 mg/0.5ml
generic
1
QL
4 / 30 days
sumatriptan succinate refill soln cart 6 mg/0.5ml
generic
1
QL
4 / 30 days
sumatriptan succinate soln a-inj 4 mg/0.5ml
generic
1
QL
4 / 30 days
sumatriptan succinate soln a-inj 6 mg/0.5ml
generic
1
QL
4 / 30 days
sumatriptan succinate soln prsyr 4 mg/0.5ml
generic
1
QL
4 / 30 days
sumatriptan succinate soln prsyr 6 mg/0.5ml
generic
1
QL
4 / 30 days
SUMATRIPTAN SUCCINATE SOLN PRSYR 6
MG/0.5ML
sumatriptan succinate
BRAND
2
QL
4 / 30 days
sumatriptan succinate solution 4 mg/0.5ml
generic
1
QL
4 / 30 days
sumatriptan succinate solution 6 mg/0.5ml
generic
1
QL
4 / 30 days
sumatriptan succinate tab 100 mg
generic
1
QL
9 / 30 days
generic
1
QL
9 / 30 days
generic
1
QL
9 / 30 days
zolmitriptan tab 2.5 mg
generic
1
QL
9 / 30 days
zolmitriptan tab 5 mg
generic
1
QL
9 / 30 days
zolmitriptan tab disp 2.5 mg
generic
1
QL
9 / 30 days
zolmitriptan tab disp 5 mg
generic
1
QL
9 / 30 days
ZOMIG SOLUTION 2.5 MG
zolmitriptan
BRAND
2
QL
9 / 30 days
ZOMIG SOLUTION 5 MG
zolmitriptan
BRAND
2
QL
6 / 30 days
PAGE 173
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ZOMIG TAB 2.5 MG
zolmitriptan
BRAND
2
QL
9 / 30 days
ZOMIG TAB 5 MG
zolmitriptan
BRAND
2
QL
9 / 30 days
calcium chloride solution 10 %
generic
1
calcium gluconate solution 10 %
generic
1
dextrose in lactated ringers solution 5 %
generic
1
dextrose in ringers solution 5 %
generic
1
DEXTROSE-NACL SOLUTION 10-0.2 %
dextrose w/ sodium chloride
BRAND
2
BRAND
2
BRAND
2
dextrose-nacl solution 10-0.9 %
generic
1
dextrose-nacl solution 2.5-0.45 %
generic
1
generic
1
BRAND
2
BRAND
2
generic
1
generic
1
generic
1
IONOSOL-B IN D5W SOLUTION
electrolyte-b in dextrose
BRAND
2
IONOSOL-MB IN D5W SOLUTION
electrolyte-mb in dextrose
BRAND
2
ISOLYTE-H IN D5W SOLUTION
electrolyte-h in dextrose
BRAND
2
ISOLYTE-P IN D5W SOLUTION
electrolyte-p in dextrose
BRAND
2
ISOLYTE-S SOLUTION
electrolyte-s
BRAND
2
*MINERALS & ELECTROLYTES*
*Calcium**
*Electrolyte Mixtures**
PAGE 174
PRODUCT DESCRIPTION
BRAND/GEN
KCL IN D5W LACTATED RINGERS
SOLUTION 40 MEQ/L
potassium chloride in d5w lactated ringers
BRAND
2
kcl in dextrose-nacl solution 10-5-0.2 meq/l-%%
generic
1
generic
1
generic
1
KCL IN DEXTROSE-NACL SOLUTION 20-50.225 MEQ/L-%-%
potassium chloride in dextrose & sodium
chloride
BRAND
2
generic
1
generic
1
generic
1
generic
1
generic
1
generic
1
KCL IN DEXTROSE-NACL SOLUTION 40-50.9 MEQ/L-%-%
potassium chloride in dextrose & sodium
chloride
BRAND
2
generic
1
KCL-LACTATED RINGERS-D5W SOLUTION
20 MEQ/L
potassium chloride in d5w lactated ringers
BRAND
2
kcl-lactated ringers-d5w solution 20 meq/l
generic
1
lactated ringers solution
generic
1
NORMOSOL-R IN D5W SOLUTION
electrolyte-r in dextrose
BRAND
2
PLASMA-LYTE-56 IN D5W SOLUTION
electrolyte-56 in dextrose
BRAND
2
potassium chloride in dextrose solution 20-5
meq/l-%
generic
1
PAGE 175
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
meq/l-%
generic
1
meq/l-%
generic
1
epiflur chew tab 0.55 (0.25 f) mg
generic
0
AL
Up to 5 yrs old
epiflur chew tab 1.1 (0.5 f) mg
generic
0
AL
Up to 5 yrs old
epiflur chew tab 2.2 (1 f) mg
generic
0
AL
Up to 5 yrs old
FLUOR-A-DAY CHEW TAB 0.25 (F)-236.79
MG
sodium fluoride-xylitol
BRAND
0
AL
Up to 5 yrs old
FLUOR-A-DAY CHEW TAB 0.5 (F)-236.79 MG
BRAND
0
AL
Up to 5 yrs old
FLUOR-A-DAY CHEW TAB 1 (F)-236.79 MG
BRAND
0
AL
Up to 5 yrs old
fluor-a-day solution 0.275 (0.125 f) mg/drop
generic
0
AL
Up to 5 yrs old
FLUORABON SOLUTION 0.55 (0.25 F)
MG/0.6ML
sodium fluoride
BRAND
0
AL
Up to 5 yrs old
fluoritab chew tab 1.1 (0.5 f) mg
generic
0
AL
Up to 5 yrs old
fluoritab chew tab 2.2 (1 f) mg
generic
0
AL
Up to 5 yrs old
fluoritab solution 0.275 (0.125 f) mg/drop
generic
0
AL
Up to 5 yrs old
FLURA-DROPS SOLUTION 0.55 (0.25 F)
MG/DROP
sodium fluoride
BRAND
0
AL
Up to 5 yrs old
LOZI-FLUR LOZENGE 2.2 (1 F) MG
sodium fluoride
BRAND
0
AL
Up to 5 yrs old
ludent chew tab 0.55 (0.25 f) mg
generic
0
AL
Up to 5 yrs old
ludent chew tab 1.1 (0.5 f) mg
generic
0
AL
Up to 5 yrs old
ludent chew tab 2.2 (1 f) mg
generic
0
AL
Up to 5 yrs old
renaf chew tab 0.55 (0.25 f) mg
generic
0
AL
Up to 5 yrs old
renaf chew tab 1.1 (0.5 f) mg
generic
0
AL
Up to 5 yrs old
renaf chew tab 2.2 (1 f) mg
generic
0
AL
Up to 5 yrs old
sodiphluor solution 1.1 (0.5 f) mg/ml
generic
0
AL
Up to 5 yrs old
*Fluoride**
PAGE 176
PRODUCT DESCRIPTION
BRAND/GEN
TIER
sodium fluoride 1.1 (0.5 f) mg
generic
0
AL
Up to 5 yrs old
sodium fluoride chew tab 0.55 (0.25 f) mg
generic
0
AL
Up to 5 yrs old
sodium fluoride chew tab 1.1 (0.5 f) mg
generic
0
AL
Up to 5 yrs old
sodium fluoride chew tab 2.2 (1 f) mg
generic
0
AL
Up to 5 yrs old
sodium fluoride solution 1.1 (0.5 f) mg/ml
generic
0
AL
Up to 5 yrs old
sodium fluoride tab 1.1 (0.5 f) mg
generic
0
AL
Up to 5 yrs old
sodium fluoride tab 2.2 (1 f) mg
generic
0
AL
Up to 5 yrs old
SODIUM FLUORIDE TAB 2.2 (1 F) MG
sodium fluoride
BRAND
0
AL
Up to 5 yrs old
potassium phosphate dibasic solution 3
mmole/ml
generic
1
potassium phosphates dibasic solution 3
mmole/ml
generic
1
effer-k effer tab 25 meq
generic
1
epiklor packet 20 meq
generic
1
epiklor/25 packet 25 meq
generic
1
k-effervescent effer tab 25 meq
generic
1
K-TAB TAB ER 20 MEQ
potassium chloride
BRAND
3
k-vescent effer tab 25 meq
generic
1
k-vescent packet 20 meq
generic
1
klor-con 10 tab er 10 meq
generic
1
KLOR-CON M15 TAB ER 15 MEQ
potassium chloride microencapsulated crystals
cr
BRAND
2
klor-con packet 20 meq
generic
1
KLOR-CON PACKET 25 MEQ
potassium chloride
BRAND
2
klor-con/ef effer tab 25 meq
generic
1
potassium acetate solution 2 meq/ml
generic
1
potassium acetate solution 4 meq/ml
generic
1
potassium bicarbonate effer tab 25 meq
generic
1
*Phosphate**
*Potassium**
PAGE 177
PRODUCT DESCRIPTION
BRAND/GEN
TIER
potassium chloride crys er tab er 10 meq
generic
1
potassium chloride er cap er 10 meq
generic
1
potassium chloride er tab er 10 meq
generic
1
POTASSIUM CHLORIDE ER TAB ER 20 MEQ
potassium chloride
BRAND
3
potassium chloride packet 20 meq
generic
1
potassium chloride solution 0.4 meq/ml
generic
1
potassium chloride solution 10 meq/100ml
generic
1
generic
1
POTASSIUM CHLORIDE SOLUTION 10
MEQ/50ML
potassium chloride
BRAND
2
potassium chloride solution 2 meq/ml
generic
1
generic
1
POTASSIUM CHLORIDE SOLUTION 30
MEQ/100ML
potassium chloride
BRAND
2
generic
1
bd posiflush solution 0.9 %
generic
1
kendall sodium chloride flush solution 0.9 %
generic
1
monoject flush syringe solution 0.9 %
generic
1
monoject sodium chloride flush solution 0.9 %
generic
1
normal saline flush solution 0.9 %
generic
1
saline flush solution 0.9 %
generic
1
saline flush zr solution 0.9 %
generic
1
sodium chloride flush solution 0.9 %
generic
1
generic
1
generic
1
sodium chloride solution 2.5 meq/ml
generic
1
sodium chloride solution 3 %
generic
1
sodium chloride solution 4 meq/ml
generic
1
sodium chloride solution 5 %
generic
1
swabflush saline flush solution 0.9 %
generic
1
*Sodium**
PAGE 178
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*MOUTH/THROAT/DENTAL AGENTS*
*Anesthetics Topical Oral**
FIRST-MOUTHWASH BLM SUSPENSION
diphenhydramine-lidocaine-alum hydroxide-mg
hydroxide-simeth
BRAND
2
generic
1
lidocaine viscous solution 2 %
generic
1
FIRST-MARYS MOUTHWASH SUSPENSION
diphenhydramine-hydrocortisone-nystatintetracycline
BRAND
2
nystatin suspension 100000 unit/ml
generic
1
chlorhexidine gluconate solution 0.12 %
generic
1
paroex solution 0.12 %
generic
1
periogard solution 0.12 %
generic
1
cavarest gel 1.1 %
generic
1
controlrx cream 1.1 %
generic
1
controlrx paste 1.1 %
generic
1
denta 5000 plus cream 1.1 %
generic
1
dentagel gel 1.1 %
generic
1
fluoridex daily defense gel 1.1 %
generic
1
phos-flur gel 1.1 %
generic
1
sf 5000 plus cream 1.1 %
generic
1
sf gel 1.1 %
generic
1
BRAND
4
oralone paste 0.1 %
generic
1
triamcinolone acetonide paste 0.1 %
generic
1
generic
1
*Anti-infectives - Throat**
*Antiseptics - Mouth/Throat**
*Dental Products**
*Periodontal Products**
ARESTIN MISC 1 MG
minocycline hcl (subgingival)
PA
*Steroids - Mouth/Throat**
*Throat Products - Misc.**
cevimeline hcl cap 30 mg
PAGE 179
PRODUCT DESCRIPTION
BRAND/GEN
TIER
pilocarpine hcl tab 5 mg
generic
1
pilocarpine hcl tab 7.5 mg
generic
1
generic
0
*MULTIVITAMINS*
*B-Complex w/ Folic Acid**
b-plex tab
DIALYVITE 3000 TAB 3 MG
b-complex w/ c-biotin-e-minerals & folic acid
BRAND
DIALYVITE 5000 TAB 5 MG
b-complex w/ c-biotin-e-minerals & folic acid
BRAND
dialyvite tab
generic
DIALYVITE/ZINC TAB
b-complex w/ c-zn & folic acid
BRAND
folbee plus cz tab 5 mg
generic
folbee plus tab
mynephrocaps cap 1 mg
generic
generic
NEPHPLEX RX TAB
b-complex w/ c-zn & folic acid
BRAND
NEPHROCAPS QT TAB DISP 1 MG
b-complex w/ c-biotin-d & folic acid
BRAND
nephronex tab
generic
NUTRIVIT LIQUID
b-complex w/ lysine-min-fe & folic acid
BRAND
rena-vite rx tab 1 mg
generic
renal cap 1 mg
PAGE 180
generic
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
Up to 1 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
0
0
0
0
0
0
0
0
0
0
0
0
0
PRODUCT DESCRIPTION
renalpren cap 1 mg
reno caps cap 1 mg
BRAND/GEN
generic
generic
SM B-COMPLEX/VITAMIN C TAB
b-complex w/ c & folic acid
BRAND
SUPERVITE LIQUID
b-complex w/ lysine-zn & folic acid
BRAND
therobec tab
generic
triphrocaps cap 1 mg
virt-caps cap 1 mg
virt-vite plus tab 5 mg
generic
generic
generic
VITAL-D RX TAB 1 MG
b-complex w/ c-biotin-d-zinc & folic acid
BRAND
vol-care rx tab 1 mg
generic
TIER
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
0
0
0
0
0
0
0
0
0
0
*Iron & B12 w/ Vitamins**
PROMAR CAP
iron & b-12 w/ vitamins
BRAND
0
AL
Up to 1 yrs old
BRAND
0
AL
Up to 1 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
*Iron w/ Vitamins**
VITAFOL SYRUP
iron w/ vitamins
*Multiple Vitamins w/ Minerals & Calcium-Folic Acid**
FOLGARD OS TAB 500-1.1 MG
multiple vitamins w/ minerals & calcium-folic
acid
BRAND
PROTECTBONE WAFER 500-1 MG
BRAND
PAGE 181
0
0
PRODUCT DESCRIPTION
BRAND/GEN
TIER
acid
TL G-FOL OS TAB 500-1.1 MG
acid
BRAND
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
AL
Up to 5 yrs old
0
*Multiple Vitamins w/ Minerals**
corvita tab 1.25 mg
generic
DIALYVITE SUPREME D TAB 3 MG
multiple vitamins w/ minerals & folic acid
BRAND
GLUTOFAC-ZX TAB 2.8 MG
BRAND
MULTICHEW CHEW TAB 1 MG
BRAND
re fac-x tab 2.8 mg
generic
RENAX TAB 2.5 MG
BRAND
RENAX TAB 5.5 MG
BRAND
SUPERVITE EC TAB DR 1 MG
BRAND
SYNAGEX CAP 1.25 MG
BRAND
SYNATEK CAP 1.25 MG
BRAND
UDAMIN SP TAB 1 MG
BRAND
UDAMIN TAB 2 MG
BRAND
0
0
0
0
0
0
0
0
0
0
0
0
*Ped Multi Vitamins w/Fl & FE**
ESCAVITE CHEW TAB 0.25-7.5 MG
ped multivitamins w/fl & iron
PAGE 182
BRAND
0
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ESCAVITE D CHEW TAB 0.25-6 MG
BRAND
0
escavite lq solution 0.25-10 mg/ml
generic
0
AL
Up to 5 yrs old
multi-vit/fluoride/iron solution 0.25-10 mg/ml
generic
0
AL
Up to 5 yrs old
multi-vitamin/fluoride/iron solution 0.25-10
mg/ml
generic
0
AL
Up to 5 yrs old
MYKIDZ IRON FL SUSPENSION 0.25-10
MG/2ML
pediatric vitamins acd fluoride & iron
BRAND
0
AL
Up to 5 yrs old
phluorivit + fe solution 0.25-10 mg/ml
generic
0
AL
Up to 5 yrs old
POLY-VI-FLOR/IRON CHEW TAB 0.5-10 MG
BRAND
0
AL
Up to 5 yrs old
POLY-VI-FLOR/IRON SUSPENSION 0.25-7
MG/ML
BRAND
0
AL
Up to 5 yrs old
poly-vitamin/fluoride/iron solution 0.25-10
mg/ml
generic
0
AL
Up to 5 yrs old
POLY-VITAMIN/FLUORIDE/IRON SOLUTION
0.5-10 MG/ML
BRAND
0
AL
Up to 5 yrs old
polyvits/fluoride/iron solution 0.25-10 mg/ml
generic
0
AL
Up to 5 yrs old
TL-FLUORIVITE CHEW TAB 0.25-7.5 MG
BRAND
0
AL
Up to 5 yrs old
TRI-VIT/FLUORIDE/IRON SOLUTION 0.25-10
MG/ML
pediatric vitamins acd fluoride & iron
BRAND
0
AL
Up to 5 yrs old
tri-vitamin/iron/fluoride solution 0.25-10 mg/ml
generic
0
AL
Up to 5 yrs old
multi vitamin/fluoride chew tab 0.25 mg
generic
0
AL
Up to 5 yrs old
multi vitamin/fluoride chew tab 1 mg
generic
0
AL
Up to 5 yrs old
multi-vit/fluoride solution 0.25 mg/ml
generic
0
AL
Up to 5 yrs old
multi-vit/fluoride solution 0.5 mg/ml
generic
0
AL
Up to 5 yrs old
multi-vitamin/fluoride chew tab 0.25 mg
generic
0
AL
Up to 5 yrs old
multi-vitamin/fluoride chew tab 0.5 mg
generic
0
AL
Up to 5 yrs old
multi-vitamin/fluoride chew tab 1 mg
generic
0
AL
Up to 5 yrs old
*Ped MV w/ Fluoride**
PAGE 183
PRODUCT DESCRIPTION
BRAND/GEN
multi-vitamin/fluoride solution 0.25 mg/ml
generic
0
AL
Up to 5 yrs old
multi-vitamins/fluoride solution 0.5 mg/ml
generic
0
AL
Up to 5 yrs old
multivitamin/fluoride chew tab 0.25 mg
generic
0
AL
Up to 5 yrs old
multivitamin/fluoride chew tab 0.5 mg
generic
0
AL
Up to 5 yrs old
multivitamin/fluoride chew tab 1 mg
generic
0
AL
Up to 5 yrs old
multivitamins/fluoride chew tab 0.25 mg
generic
0
AL
Up to 5 yrs old
multivitamins/fluoride chew tab 0.5 mg
generic
0
AL
Up to 5 yrs old
multivitamins/fluoride chew tab 1 mg
generic
0
AL
Up to 5 yrs old
mvc-fluoride chew tab 0.25 mg
generic
0
AL
Up to 5 yrs old
mvc-fluoride chew tab 0.5 mg
generic
0
AL
Up to 5 yrs old
mvc-fluoride chew tab 1 mg
generic
0
AL
Up to 5 yrs old
phluorivit solution 0.25 mg/ml
generic
0
AL
Up to 5 yrs old
phluorivit solution 0.5 mg/ml
generic
0
AL
Up to 5 yrs old
POLY-VI-FLOR CHEW TAB 0.25 MG
pediatric multivitamins w/fl
BRAND
0
AL
Up to 5 yrs old
POLY-VI-FLOR CHEW TAB 0.5 MG
BRAND
0
AL
Up to 5 yrs old
POLY-VI-FLOR CHEW TAB 1 MG
BRAND
0
AL
Up to 5 yrs old
POLY-VI-FLOR SUSPENSION 0.25 MG/ML
BRAND
0
AL
Up to 5 yrs old
poly-vitamin/fluoride solution 0.25 mg/ml
generic
0
AL
Up to 5 yrs old
poly-vitamin/fluoride solution 0.5 mg/ml
generic
0
AL
Up to 5 yrs old
polyvitamin/fluoride solution 0.25 mg/ml
generic
0
AL
Up to 5 yrs old
polyvitamin/fluoride solution 0.5 mg/ml
generic
0
AL
Up to 5 yrs old
QUFLORA PEDIATRIC CHEW TAB 0.25 MG
BRAND
0
AL
Up to 5 yrs old
QUFLORA PEDIATRIC CHEW TAB 0.5 MG
BRAND
0
AL
Up to 5 yrs old
QUFLORA PEDIATRIC CHEW TAB 1 MG
BRAND
0
AL
Up to 5 yrs old
QUFLORA PEDIATRIC SOLUTION 0.25
BRAND
0
PAGE 184
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
MG/ML
QUFLORA PEDIATRIC SOLUTION 0.5 MG/ML
BRAND
0
re multivit with fluoride chew tab 0.25 mg
generic
0
AL
Up to 5 yrs old
re multivit with fluoride chew tab 0.5 mg
generic
0
AL
Up to 5 yrs old
re multivit with fluoride chew tab 1 mg
generic
0
AL
Up to 5 yrs old
TRI-VI-FLOR SUSPENSION 0.25 MG/ML
pediatric vitamins acd & l-methylfolate w/
fluoride
BRAND
0
AL
Up to 5 yrs old
TRI-VI-FLOR SUSPENSION 0.5 MG/ML
fluoride
BRAND
0
AL
Up to 5 yrs old
TRI-VI-FLORO SUSPENSION 0.25 MG/ML
fluoride
BRAND
0
AL
Up to 5 yrs old
TRI-VI-FLORO SUSPENSION 0.5 MG/ML
fluoride
BRAND
0
AL
Up to 5 yrs old
tri-vit/fluoride solution 0.25 mg/ml
generic
0
AL
Up to 5 yrs old
tri-vit/fluoride solution 0.5 mg/ml
generic
0
AL
Up to 5 yrs old
tri-vitamin/fluoride solution 0.25 mg/ml
generic
0
AL
Up to 5 yrs old
tri-vitamin/fluoride solution 0.5 mg/ml
generic
0
AL
Up to 5 yrs old
TRIPHLUORIVIT SOLUTION 0.25 MG/ML
pediatric vitamins acd w/ fluoride
BRAND
0
AL
Up to 5 yrs old
triple-vitamin/fluoride solution 0.25 mg/ml
generic
0
AL
Up to 5 yrs old
vitamins acd-fluoride solution 0.25 mg/ml
generic
0
AL
Up to 5 yrs old
ACTIVE OB CAP 20-1-320 MG
prenatal w/o vit a w/ fe carbonyl-folic acid-dha
GL
BRAND
Female
3
AL
11 to 50 yrs old
ATABEX EC TAB DR 29-1 MG
prenatal vit w/ docusate-iron carbonyl-folic acid
GL
BRAND
Female
AL
11 to 50 yrs old
B-NEXA TAB 1.2 MG
prenatal w/ calcium-vit b6-folic acid-ginger
GL
BRAND
Female
AL
11 to 50 yrs old
B-NEXA TAB 1.22 MG
BRAND
GL
Female
*Prenatal Vitamins**
PAGE 185
3
3
3
PRODUCT DESCRIPTION
BRAND/GEN
TIER
BAL-CARE DHA ESSENTIAL MISC 27-1 & 374
MG
prenatal w/fe polysacch cmplx-sod feredetatefa-omega 3
BRAND
BAL-CARE DHA MISC 27-1 & 430 MG
BRAND
BP FOLINATAL PLUS B TAB 1 MG
prenatal w/ calcium carbonate-vit b6-vit b12folic acid
BRAND
BP MULTINATAL PLUS CHEW TAB 40-1 MG
prenatal without a vit w/ fe fumarate-folic acid
BRAND
BP MULTINATAL PLUS TAB 30-1 MG
BRAND
C-NATE DHA CAP 28-1-200 MG
prenatal vit w/ ferrous fumarate-fa-omega 3
fatty acids
BRAND
CALCIUM PNV CAP 28-1-250 MG
prenatal without vit a w/ fe fum-fa-omega fatty
acids
BRAND
3
CAVAN ONE OMEGA CAP 27-1 MG
prenatal vit w/ iron carbonyl-fe aspart glyc-faomega 3
BRAND
3
CAVAN PRENATAL/EC CALCIUM TAB DR 281 MG
BRAND
CAVAN-ALPHA KIT 27-1 & 300 MG
BRAND
CAVAN-EC SOD DHA MISC 30-1 & 440 MG
prenatal vit w/ sodium feredetate-folic acidomega 3
BRAND
CAVAN-FOLATE DHA MISC 65-1 & 250 MG
prenatal mv & min w/ ferrous fumarate-l
methylfolate-dha
BRAND
cavan-folate ob tab 65-1 mg
generic
CAVAN-HEME OMEGA MISC 28-1 & 200 MG
prenatal w/o vit a w/ iron-fa-dha
PAGE 186
BRAND
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
3
3
3
3
3
3
3
3
3
3
0
3
AL
PRODUCT DESCRIPTION
BRAND/GEN
TIER
11 to 50 yrs old
CHOICE-OB+DHA MISC 29-1 & 250 MG
prenatal mv & min w/fe polysaccharide
complex-fa-dha
BRAND
CITRANATAL 90 DHA MISC 90-1 & 300 MG
prenatal w/o vit a w/ fe carbonyl-fe gluconatedss-fa-dha
BRAND
CITRANATAL ASSURE MISC 300 MG
BRAND
CITRANATAL B-CALM MISC 20-1 & 25 (2) MG
prenatal w/o vit a w/ fe carbonyl-fe gluconate-fa
& vit b6
BRAND
CITRANATAL DHA MISC 27-1 & 250 MG
BRAND
CITRANATAL HARMONY CAP 27-1-250 MG
prenatal w/o vit a w/ fe carbonyl-dss-fa-dha
BRAND
prenatal w/o vit a w/ fe fumarate-fe carbonyldss-fa-dha
BRAND
BRAND
BRAND
BRAND
CITRANATAL RX TAB 27-1 MG
prenatal without vit a w/ fe carbonyl-fe glucdocusate-fa
BRAND
COMPLETE NATAL DHA MISC 29-1-200 &
250 MG
prenatal mv & min w/fe bisglyc-fe prot succ-faca-omega 3
BRAND
COMPLETE-RF PRENATAL TAB 90-1 MG
prenatal without a w/ fe carbonyl-docusate-folic
acid
BRAND
COMPLETENATE CHEW TAB 29-1 MG
prenatal vit w/ ferrous fumarate-folic acid
BRAND
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
PAGE 187
PRODUCT DESCRIPTION
BRAND/GEN
CONCEPT DHA CAP 53.5-38-1 MG
prenatal vit w/ fe fum-iron polysacch complex fa-omega 3
BRAND
CONCEPT OB CAP 130-92.4-1 MG
prenatal without a vit w/ fe fum-iron polysacch
complex -fa
BRAND
CORENATE-DHA MISC 35-1 & 300 MG
BRAND
DOCOSAVIT CAP 15-15-1 MG
BRAND
DUET DHA 400 MISC 25-1 & 400 MG
BRAND
DUET DHA 400EC MISC 25-1 & 400 MG (DR)
BRAND
DUET DHA 430 MISC 25-1 & 430 MG
BRAND
DUET DHA 430EC MISC 25-1 & 430 MG (DR)
BRAND
DUET DHA BALANCED MISC 24-1 & 272 MG
BRAND
BRAND
BRAND
BRAND
BRAND
DUET DHA COMPLETE MISC 27-1 & 430 MG
BRAND
DUET DHA EC MISC 25-1 & 400 MG (DR)
prenatal w/fe polysacch cmplx-sod feredetate-
BRAND
PAGE 188
TIER
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
3
3
3
3
3
3
3
3
3
3
3
3
3
3
PRODUCT DESCRIPTION
BRAND/GEN
TIER
fa-omega 3
DUET DHA EC MISC 25-1 & 430 MG (DR)
BRAND
DUET DHA MISC 25-1 & 400 MG
BRAND
DUET DHA MISC 25-1 & 430 MG
BRAND
EDGE OB CHEW TAB 29-1 MG
prenatal vit w/ iron polysaccharide complexfolic acid
BRAND
ELITE OB WITH DHA CAP 28-1.25-200 MG
fatty acids
BRAND
ELITE-OB 400 CAP 35-5-1.2 MG
prenatal vit w/ fe carbonyl-fe bisglycinate-fa-fish
oil
BRAND
ELITE-OB TAB 50-1.25 MG
prenatal vit w/ iron carbonyl-folic acid
BRAND
EXTRA-VIRT PLUS DHA CAP 29-1.25-350 MG
prenatal w/o vit a w/fe fumarate-docusate cafolic acid-dha
BRAND
FEMECAL OB TAB 22-6-1 MG
prenatal vit w/ fe polysacch complex-fe asp-fe
glyc-fa
BRAND
FOCALGIN-B TAB 1.22 MG
BRAND
FOLBECAL TAB 1 MG
BRAND
FOLCAL DHA CAP 27-1.25-300 MG
prenatal w/o vit a w/ fe fumarate-dss-fa-dha
BRAND
FOLCAPS CARE ONE CAP 20-7-1 MG
prenatal w/fe cbnyl-fe asparto glyc-fa-dssomega 3
BRAND
FOLCAPS OMEGA 3 CAP 20-7-1 MG
prenatal w/ fe carbonyl-fe asp-fe glyc-fa-omega
fatty acids
BRAND
FOLCAPS OMEGA 3 CAP 27-1 MG
BRAND
PAGE 189
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
PRODUCT DESCRIPTION
BRAND/GEN
TIER
FOLIVANE-OB CAP 130-92.4-1 MG
complex -fa
BRAND
FOLIVANE-PRX DHA NF CAP 30-1.24-265
MG
BRAND
GESTICARE DHA MISC 27-1 & 250 MG
prenatal mv & min w/fe fumarate-fa-dha
BRAND
GESTICARE TAB DR 28-1 MG
BRAND
HEMENATAL OB + DHA MISC 28-6-1 & 203
MG
prenatal vit w/ fe poly cmplx-fe heme polypeptfa & omega 3
BRAND
HEMENATAL OB TAB 28-6-1 MG
prenatal vit w/ fe polysacch complex-fe heme
polypeptide-fa
BRAND
INATAL ADVANCE TAB
BRAND
INATAL GT TAB
BRAND
INATAL ULTRA TAB
BRAND
INATAL ULTRA TAB 90-1 MG
BRAND
INFANATE BALANCE CAP 29-1-265 MG
BRAND
INFANATE DHA CAP 28-1-250 MG
acids
BRAND
KOLNATAL DHA MISC 27-1 & 250 MG
BRAND
L-METHYLFOLATE PNV DHA CAP 27-1.130.4 MG
prenatal vit w/ ferrous fumarate-l methylfolate-
BRAND
PAGE 190
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
3
3
3
3
3
3
3
3
3
3
3
3
3
3
PRODUCT DESCRIPTION
BRAND/GEN
TIER
fa-dha
lactocal-f tab
generic
LEVOMEFOLATE DHA CAP 27-1.13-0.4 MG
prenatal vit w/ ferrous fumarate-l methylfolatefa-dha
BRAND
LEVOMEFOLATE PNV MISC 29-1.4-0.5 MG
prenatal vit w/ iron polysaccharide cmplx-l
methylfolate-fa
BRAND
M-VIT TAB
BRAND
MACNATAL CN DHA CAP 28-1-250 MG
BRAND
MARNATAL-F CAP 60-1 MG
prenatal without vit a w/ iron polysaccharide
complex-fa
BRAND
MAXINATE TAB 20-0.8 MG
prenatal vit w/ fe gluconate-fe fumarate-folic
acid
BRAND
MOMS CHOICE RX MISC 26-1 & 278 MG
BRAND
MULTI-NATE 30 DHA MISC 29-1-200 & 400
MG
BRAND
MULTI-NATE 30 DHA MISC 29-1-200 & 430
MG
BRAND
MULTI-NATE 30 TAB 29-1 MG
prenatal vit w/ fe bisglycinate-fe protein succfolic acid
BRAND
MULTI-NATE DHA EXTRA MISC 29-1-200 &
400 MG (DR)
BRAND
MULTI-NATE DHA EXTRA MISC 29-1-200 &
430 MG (DR)
BRAND
MYNATAL ADVANCE TAB
BRAND
PAGE 191
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
0
3
3
3
3
3
3
3
3
3
3
3
3
3
PRODUCT DESCRIPTION
BRAND/GEN
TIER
MYNATAL CAP
prenatal multivit-min w/fe-fa
BRAND
mynatal plus tab
generic
MYNATAL TAB 90-1 MG
BRAND
mynatal-z tab
generic
MYNATE 90 PLUS TAB ER
prenatal vit w/ docusate-fe fumarate-folic acid
BRAND
NATA KOMPLETE TAB 25-1 MG
prenatal vit w/ fe fum-fe bisglycinate chelatefolic acid
BRAND
NATACHEW CHEW TAB 28-1 MG
prenatal vit w/ fe fum-fe bisglycinate chelatefolic acid
BRAND
NATACHEW CHEW TAB 29-1 MG
BRAND
NATAFORT TAB 60-1 MG
prenatal without a vit w/ fe carbonyl-fe
fumarate-folic acid
BRAND
NATAL-V RX TAB 29-1 MG
BRAND
NATALVIRT 90 DHA MISC 90-1 & 300 MG
BRAND
NATALVIRT CA MISC 35-1 & 300 MG
BRAND
NATALVIT TAB
BRAND
NATELLE EZ TAB 25-1 MG
prenatal vit w/ fe bisglycinate chelate-folic acid
BRAND
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
3
0
3
0
3
3
3
3
3
3
3
3
3
3
3
PAGE 192
PRODUCT DESCRIPTION
BRAND/GEN
NATELLE ONE CAP 28-1-250 MG
acids
BRAND
NATELLE-EZ TAB 25-0.8 MG
BRAND
NAVATAB + DHA MISC 26-1 & 200 MG
prenatal mv & min w/fe bisglycinate-fa-dha
BRAND
NEEVO DHA CAP 27-1.13 MG
prenatal without vit a w/ fe fumarate-l
methylfolate-omegas
BRAND
NEEVO DHA CAP 27-1.53 MG
prenatal without a w/ fe fumarate-l methylfolatefa-omegas
BRAND
NEEVO MISC 29-1.4-0.5 MG
methylfolate-fa
BRAND
NESTABS ABC MISC 32-1-200 MG
prenatal mv & min w/o vit a w/fe polysac cmplxfa-ca-omega 3
BRAND
NESTABS DHA MISC 32-1 MG
prenatal vit without vit a w/ fe bisglycinate-faomeg 3
BRAND
NESTABS TAB 32-1 MG
prenatal vit without vit a w/ fe bisglycinate-folic
acid
BRAND
NEWGEN TAB 32-1 MG
acid
BRAND
3
NEXA PLUS CAP 29-1.25-350 MG
BRAND
3
NEXA SELECT CAP 29-1.25-325 MG
BRAND
NEXA SELECT CAP 29-1.25-337.5 MG
BRAND
NUTRI-TAB OB + DHA MISC 32-1 MG
BRAND
NUTRI-TAB OB TAB 32-1 MG
acid
BRAND
PAGE 193
TIER
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
3
3
3
3
3
3
3
3
3
3
3
3
PRODUCT DESCRIPTION
BRAND/GEN
O-CAL FA TAB 27-1 MG
BRAND
O-CAL PRENATAL TAB
BRAND
OB COMPLETE 400 CAP 35-5-1.2 MG
oil
BRAND
OB COMPLETE 400 CAP 40-10-1-400 MG
prenatal w/o vit a w/ fe carbonyl-fe aspart glycfa-fish oil
BRAND
OB COMPLETE CHEW TAB 15-5-1-100 MG
prenatal w/o vit a w/ fe carbonyl-fe aspart glycfa-dha
BRAND
OB COMPLETE ONE CAP 50-1-476 MG
prenatal w/o vit a w/ fe carbonyl-fe aspart glycfa-fish oil
BRAND
OB COMPLETE PETITE CAP 35-5-1-200 MG
prenatal w/o vit a w/ fe carbonyl-fe aspart glycfa-omega 3
BRAND
OB COMPLETE PREMIER TAB 30-20-1 MG
prenatal vit w/ iron carbonyl-fe aspart glycinatefa
BRAND
OB COMPLETE TAB 50-1.25 MG
BRAND
OB COMPLETE WITH DHA CAP 28-1.25-200
MG
fatty acids
BRAND
OB COMPLETE/DHA CAP 30-10-1-200 MG
prenat vit w/ iron carbonyl-fe asp glyc-fa-omega
fatty acid
BRAND
OB-NATAL ONE CAP 27-1 MG
BRAND
OBSTETRIX DHA MISC 29-1 & 387 MG
prenatal w/fe carbonyl-fa-dss-omega 3 fatty
acids
BRAND
OBSTETRIX EC TAB 29-1 MG
BRAND
PAIRE OB MISC 22-6-1 & 200 MG
prenatal vit w/ fe polysacch cmplx-fe asp-fe
BRAND
PAGE 194
TIER
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
AL
PRODUCT DESCRIPTION
BRAND/GEN
TIER
glyc-fa & dha
pnv fe fum/docusate/folic acid tab 29-1 mg
11 to 50 yrs old
generic
PNV FOLIC ACID + IRON TAB 27-1 MG
BRAND
PNV OB+DHA MISC 27-1 & 250 MG
BRAND
PNV PRENATAL PLUS MULTIVITAMIN TAB
27-1 MG
BRAND
PNV TABS 29-1 TAB 29-1 MG
BRAND
3
PNV-DHA CAP 27-0.6-0.4-300 MG
prenatal without a w/ fe fumarate-l methylfolatefa-dha
BRAND
3
PNV-DHA+DOCUSATE CAP 27-1.25-300 MG
BRAND
PNV-FIRST CAP 29-1-200 MG
complex-fa-dha
BRAND
PNV-OB/DHA MISC 65-1 & 250 MG
BRAND
PNV-OMEGA CAP 28-0.6-0.4-340 MG
prenatal without a w/ fe fumarate-l methylfolatefa-omega 3
BRAND
PNV-SELECT TAB 27-0.6-0.4 MG
prenatal vit w/ ferrous fumarate-l methylfolatefolic acid
BRAND
PNV-TOTAL CAP 35-5-1.2 MG
oil
BRAND
PR NATAL 400 EC MISC 29-1-200 & 400 MG
(DR)
BRAND
PR NATAL 400 MISC 29-1-200 & 400 MG
BRAND
PR NATAL 430 EC MISC 29-1-200 & 430 MG
BRAND
PAGE 195
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
0
3
3
3
3
3
3
3
3
3
3
3
3
PRODUCT DESCRIPTION
BRAND/GEN
TIER
(DR)
PR NATAL 430 MISC 29-1-200 & 430 MG
BRAND
PR NATAL 440 EC MISC 30-1 & 440 MG
prenatal vit w/ sodium feredetate-folic acidomega 3
BRAND
PREFERA OB + DHA MISC 28-6-1 & 203 MG
BRAND
PREFERA OB TAB 28-6-1 MG
polypeptide-fa
BRAND
PREFERAOB ONE CAP 22-6-1-200 MG
prenatal vit w/ fe polysacch cmplx-fe heme
polypept-fa & dha
BRAND
PREFOL-DHA CAP 26-1.2-300 MG
BRAND
PRENA1 CHEW TAB 1.4 MG
prenatal w/ vit b2-b6-b12-cholecalciferol-folic
acid
BRAND
3
PRENA1 PEARL CAP ER 30-1.4-200 MG
prenatal without a w/ fe fumarate-sod
feredetate-fa-dha
BRAND
3
PRENA1 PLUS/QUATREFOLIC MISC 30-0.60.4 &300 MG
prenatal without a w/ fe chelate-l methylfolatefa-dha
BRAND
PRENA1/QUATREFOLIC CAP 30-0.6-0.4-200
MG
BRAND
PRENA1/QUATREFOLIC CHEW TAB 0.6-0.4
MG
prenatal w/ vit b2-b6-b12-cholecalciferol-l
methylfolate-fa
BRAND
PRENACARE TAB 90-1 MG
BRAND
PRENAFIRST TAB 17-1 MG
BRAND
PAGE 196
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
3
3
3
3
3
3
3
3
3
3
3
PRODUCT DESCRIPTION
BRAND/GEN
PRENAISSANCE 90 DHA MISC 90-1 & 300
MG
BRAND
PRENAISSANCE BALANCE CAP 30-1-260
MG
BRAND
PRENAISSANCE CAP 29-1.25-325 MG
BRAND
PRENAISSANCE DHA MISC 27-1 & 250 MG
BRAND
PRENAISSANCE HARMONY DHA MISC 27-1
& 380 MG
BRAND
PRENAISSANCE NEXT TAB 1.2 MG
BRAND
PRENAISSANCE NEXT-B TAB 1.22 MG
BRAND
PRENAISSANCE PLUS CAP 28-1-250 MG
BRAND
PRENAISSANCE PROMISE MISC 35-1 & 300
MG
BRAND
PRENAPLUS TAB 27-1 MG
BRAND
PRENATA CHEW TAB 29-1 MG
BRAND
PRENATABS FA TAB
BRAND
PRENATABS RX TAB 29-1 MG
BRAND
PRENATAL 19 CHEW TAB
BRAND
PRENATAL 19 CHEW TAB 29-1 MG
BRAND
PAGE 197
TIER
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
PRODUCT DESCRIPTION
BRAND/GEN
TIER
prenatal 19 tab
generic
BRAND
3
prenatal 19 tab 29-1 mg
generic
0
BRAND
PRENATAL FORMULA TAB 27-1 MG
BRAND
PRENATAL LOW IRON TAB 27-1 MG
BRAND
PRENATAL MV & MIN-FE-FA-DHA CAP 11-30.5-100 MG
polypept-fa & dha
BRAND
PRENATAL PLUS IRON TAB 29-1 MG
BRAND
PRENATAL PLUS TAB 27-1 MG
BRAND
PRENATAL PLUS/IRON TAB 27-1 MG
BRAND
PRENATAL TAB 27-0.8 MG
BRAND
PRENATAL TAB 27-1 MG
BRAND
PRENATAL VITAMINS PLUS TAB 27-1 MG
BRAND
PRENATAL+DHA MISC 27-1 & 250 MG
BRAND
PRENATAL-U CAP 106.5-1 MG
BRAND
PAGE 198
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
0
PRENATAL 19 TAB 29-1 MG
PRENATAL AD TAB
AL
3
3
3
3
3
3
3
3
3
3
3
3
PRODUCT DESCRIPTION
BRAND/GEN
TIER
PRENATE AM TAB 1 MG
prenatal w/ calcium-vit b6-vit b12-folic acidginger
BRAND
PRENATE CHEW TAB 0.6-0.4 MG
prenatal multivitamins & minerals w/ lmethylfolate-fa
BRAND
PRENATE DHA CAP 28-0.6-0.4-300 MG
BRAND
PRENATE ELITE TAB 26-0.6-0.4 MG
BRAND
PRENATE ELITE TAB 27-0.6-0.4 MG
BRAND
PRENATE ENHANCE CAP 28-0.6-0.4-400 MG
BRAND
PRENATE ESSENTIAL CAP 18-0.6-0.4-300
MG
prenatal w/o a w/ fe asparto glyc-l methylfolatefa-dha
BRAND
3
MG
BRAND
3
MG
prenatal without a w/ fe asp glyc-l methylfolatefa-omega 3
BRAND
PRENATE MINI CAP 29-0.6-0.4-350 MG
prenatal without a w/ fe carbonyl-l methylfolatefa-dha
BRAND
PRENATE RESTORE CAP 27-0.6-0.4-400 MG
BRAND
PRENEXA CAP 27-1.25-300 MG
BRAND
PRENEXA PREMIER CAP 27-1.25-310 MG
BRAND
PAGE 199
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
3
3
3
3
3
3
3
3
3
3
3
PRODUCT DESCRIPTION
BRAND/GEN
PREPLUS TAB 27-1 MG
BRAND
PREQUE 10 TAB 15-0.5-50 MG
prenatal mv & min w/fe carbonyl-fa-dha
BRAND
PREQUE 10 TAB 15-25-0.5-50 MG
prenatal mv & min w/fe carbonyl-docusate-folic
acid-dha
BRAND
PRETAB TAB 29-1 MG
BRAND
3
PREVITE RX TAB 1 MG
BRAND
3
PROTECTNATAL TAB DR 13.5-0.5-700 MG
prenatal vit w/polysaccharide fe-fa-fish oil
BRAND
PROVIDA OB CAP 20-20-1.25 MG
complex -fa
BRAND
PUREFE OB PLUS CAP 162-115.2-1 MG
complex -fa
BRAND
R-NATAL OB CAP 20-1-320 MG
prenatal w/o vit a w/ fe carbonyl-folic acid-dha
BRAND
RE DUALVIT OB CAP 162-115.2-1 MG
complex -fa
BRAND
RE OB + 90 DHA MISC 90-1 & 250 MG
BRAND
RE OB + DHA MISC 27-1 & 250 MG
BRAND
RE PRENATAL MULTIVITAMIN/IRON CHEW
TAB 29-1 MG
BRAND
RE-NATA 29 OB TAB 29-1 MG
BRAND
REAPHIRM CAP 29-1-200 MG
complex-fa-dha
BRAND
RELNATE DHA CAP 28-1-200 MG
BRAND
PAGE 200
TIER
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
3
3
3
3
3
3
3
3
3
3
3
3
3
3
PRODUCT DESCRIPTION
BRAND/GEN
TIER
fatty acids
SE-CARE CHEW TAB 40-1 MG
BRAND
SE-CARE CONCEIVE TAB 30-1 MG
BRAND
SE-NATAL 19 CHEW TAB 29-1 MG
BRAND
se-natal 19 tab 29-1 mg
generic
SE-NATAL 90 TAB ER 90-1 MG
BRAND
se-natal one tab 60-1 mg
generic
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
3
3
3
0
3
0
SE-PLETE DHA CAP 28-1.25-200 MG
fatty acids
BRAND
SE-TAN DHA CAP 15-15-1 MG
BRAND
SELECT-OB CHEW TAB 29-0.6-0.4 MG
methylfolate-fa
BRAND
3
SELECT-OB CHEW TAB 29-1 MG
prenatal vit w/ iron polysaccharide complexfolic acid
BRAND
3
SELECT-OB+DHA MISC 29-1 & 250 MG
complex-fa-dha
BRAND
SETONET MISC 29-1-200 & 430 MG
BRAND
SETONET-EC MISC 29-1-200 & 430 MG (DR)
BRAND
TANDEM DHA CAP 15-15-1 MG
BRAND
PAGE 201
3
3
3
3
3
3
PRODUCT DESCRIPTION
BRAND/GEN
TANDEM OB CAP 162-115.2-1 MG
complex -fa
BRAND
TARON-BC MISC 20-1 & 25 (2) MG
prenatal without vit a w/ iron carbonyl-folic acid
& vit b6
BRAND
TARON-C DHA CAP 53.5-38-1 MG
BRAND
TARON-DUO EC MISC 29-1-200 & 400 MG
(DR)
BRAND
TARON-PREX CAP 30-1.2-265 MG
BRAND
TL-ASSURE ONE CAP 29-1-200 MG
complex-fa-dha
BRAND
TL-ASSURE+DHA MISC 29-1 & 250 MG
complex-fa-dha
BRAND
TL-CARE DHA CAP 27-1-500 MG
prenatal w/fe fumarate-fa-dss-fish oil
BRAND
TL-SELECT CAP 29-1.25-325 MG
BRAND
TL-SELECT DHA CAP 29-1.25-350 MG
BRAND
TRI RX TAB 27-1 MG
BRAND
TRI-TABS DHA MISC 32-1 MG
BRAND
TRIADVANCE TAB 90-1 MG
BRAND
TRICARE DHA 301 CAP 27-1-710 MG
BRAND
TRICARE PRENATAL COMPLEAT MISC 27-1
MG
BRAND
PAGE 202
TIER
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
PRODUCT DESCRIPTION
BRAND/GEN
TIER
prenatal without vit a w/ fe fumarate-fa-fish oil
TRICARE PRENATAL DHA ONE CAP 27-1500 MG
BRAND
TRICARE TAB
BRAND
TRIMESIS RX TAB 1 MG
BRAND
TRINATAL GT TAB 90-1 MG
BRAND
trinatal rx 1 tab 60-1 mg
generic
TRINATAL ULTRA TAB 90-1 MG
BRAND
TRINATE TAB
BRAND
TRIVEEN-DUO DHA MISC 29-1-200 & 400 MG
BRAND
TRIVEEN-ONE CAP 27-1-250 MG
acids
BRAND
TRIVEEN-PRX RNF CAP 26-1.2-300 MG
BRAND
TRIVEEN-TEN TAB 15-0.5-50 MG
prenatal mv & min w/fe carbonyl-fa-dha
BRAND
TRIVEEN-U CAP 106.5-1 MG
BRAND
TRUST NATAL DHA MISC 29-1-200 & 250 MG
BRAND
ULTIMATE OB DHA MISC 22-6-1 & 200 MG
prenatal vit w/ fe polysacch cmplx-fe asp-fe
glyc-fa & dha
BRAND
ULTIMATECARE ONE CAP 27-1 MG
prenatal vit w/ iron carbonyl-fe aspart glyc-fa-
BRAND
PAGE 203
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
3
3
3
3
0
3
3
3
3
3
3
3
3
3
3
PRODUCT DESCRIPTION
BRAND/GEN
TIER
omega 3
ULTIMATECARE ONE NF CAP 20-7-1 MG
prenatal w/fe cbnyl-fe asparto glyc-fa-dssomega 3
BRAND
ULTRA NATALCARE TAB 90-1 MG
BRAND
V-NATAL DHA MISC 32-1 MG
BRAND
V-NATAL TAB 32-1 MG
acid
BRAND
VEMAVITE-PRX 2 CAP 27-1.25-300 MG
BRAND
VENA-BAL DHA MISC 27-1 & 430 MG
BRAND
VENATAL COMPLETE DHA MISC 27-1 & 430
MG
BRAND
VENATAL-FA TAB 29-1 MG
BRAND
VINACAL B MISC 20-1 & 25 (2) MG
prenatal w/o vit a w/ fe carbonyl-fe gluconate-fa
& vit b6
BRAND
VINACAL TAB 27-1 MG
BRAND
VINATE AZ EXTRA TAB 29-1 MG
BRAND
VINATE AZ TAB 27-1 MG
BRAND
VINATE C TAB 30-1 MG
BRAND
VINATE CALCIUM TAB 27-1 MG
prenatal vit w/ iron carbonyl-fe gluconate-folic
acid
BRAND
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
PAGE 204
PRODUCT DESCRIPTION
BRAND/GEN
VINATE CARE CHEW TAB 40-1 MG
BRAND
VINATE DHA CAP 27-1.53 MG
prenatal without a w/ fe fumarate-l methylfolatefa-omegas
BRAND
VINATE DHA RF CAP 27-1.13 MG
prenatal without vit a w/ fe fumarate-l
methylfolate-omegas
BRAND
VINATE GT TAB 90-1 MG
BRAND
VINATE IC CAP 162-115.2-1 MG
complex -fa
BRAND
VINATE II TAB 29-1 MG
BRAND
VINATE M TAB 27-1 MG
prenatal vit w/ selenium-fe fumarate-folic acid
BRAND
vinate one tab 60-1 mg
generic
VINATE PN CARE TAB 30-1 MG
prenatal without a w/ fe asparto glyc-docusatefolic acid
BRAND
VINATE ULTRA TAB
BRAND
VIRT-BAL DHA MISC 13-13-1 & 374 MG
BRAND
VIRT-BAL DHA PLUS MISC 27-1 & 380 MG
BRAND
VIRT-PN DHA CAP 27-0.6-0.4-300 MG
BRAND
VIRT-PN PLUS CAP 28-0.6-0.4-340 MG
BRAND
VIRT-PN TAB 27-0.6-0.4 MG
BRAND
PAGE 205
TIER
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
3
3
3
3
3
3
0
3
3
3
3
3
3
3
PRODUCT DESCRIPTION
BRAND/GEN
VIRT-SELECT CAP 29-1.25-325 MG
BRAND
VITAFOL ULTRA CAP 29-0.6-0.4-200 MG
prenatal vit w/ fe polysacch complex-l
methylfolate-fa-dha
BRAND
VITAFOL-NANO TAB 18-0.6-0.4 MG
prenatal w/o a vit w/ fe fumarate-l methylfolatefolic acid
BRAND
vitafol-ob tab
generic
VITAFOL-OB+DHA MISC 65-1 & 250 MG
BRAND
VITAFOL-ONE CAP 29-1-200 MG
complex-fa-dha
BRAND
VITAFOL-PLUS CAP 27-1-200 MG
complex-fa-dha
BRAND
vitafol-pn tab
generic
TIER
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
3
3
3
0
3
3
3
0
VITAMEDMD ONE RX/QUATREFOLIC CAP
30-0.6-0.4-200 MG
BRAND
VITAMEDMD PLUS RX/QUATREFOLIC MISC
30-0.6-0.4 &300 MG
prenatal without a w/ fe chelate-l methylfolatefa-dha
BRAND
VITAMEDMD REDICHEW RX CHEW TAB 0.60.4 MG
prenatal w/ vit b2-b6-b12-cholecalciferol-l
methylfolate-fa
BRAND
VITAMEDMD REDICHEW RX CHEW TAB 1.4
MG
prenatal w/ vit b2-b6-b12-cholecalciferol-folic
acid
BRAND
3
VITAPEARL CAP ER 30-1.4-200 MG
prenatal without a w/ fe fumarate-sod
feredetate-fa-dha
BRAND
3
VITAPHIL + DHA MISC 26-1 & 200 MG
prenatal mv & min w/fe bisglycinate-fa-dha
BRAND
PAGE 206
3
3
3
3
PRODUCT DESCRIPTION
BRAND/GEN
VITAPHIL TAB 25-1 MG
BRAND
VITASPIRE TAB 29-1 MG
prenatal without a vit w/ iron carbonyl-folic acid
BRAND
VIVA CT PRENATAL CHEW TAB 28-1 MG
BRAND
VIVA DHA CAP 28-1-200 MG
fatty acids
BRAND
VOL-NATE TAB 28-1 MG
BRAND
VOL-PLUS TAB 27-1 MG
BRAND
VOL-TAB RX TAB 29-1 MG
BRAND
VP CH ULTRA CAP 27-1-260 MG
prenatal w/o vit a w/ fe fumarate-fe carbonyldss-fa-dha
BRAND
VP-CH PLUS CAP 29-1-265 MG
BRAND
VP-CH-PNV CAP 30-1-260 MG
BRAND
VP-ERA OB PLUS TAB 22-6-1 MG
polypeptide-fa
BRAND
VP-GGR-B6 PRENATAL TAB 1.2 MG
BRAND
VP-HEME OB + DHA MISC 28-6-1 & 203 MG
BRAND
VP-HEME OB TAB 28-6-1 MG
polypeptide-fa
BRAND
VP-HEME ONE CAP 22-6-1-200 MG
polypept-fa & dha
BRAND
TIER
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
PAGE 207
PRODUCT DESCRIPTION
BRAND/GEN
VP-PNV-DHA CAP 28-1-215.8 MG
fatty acids
BRAND
ZATEAN-CH CAP 27-1-250 MG
BRAND
ZATEAN-PN DHA CAP 27-0.6-0.4-300 MG
BRAND
ZATEAN-PN PLUS CAP 28-0.6-0.4-340 MG
BRAND
ZATEAN-PN TAB 27-0.6-0.4 MG
BRAND
ZINGIBER TAB 1.2 MG
BRAND
TIER
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
QL
120 / 30 days
3
3
3
3
3
*MUSCULOSKELETAL THERAPY AGENTS*
*Central Muscle Relaxants**
baclofen tab 10 mg
generic
1
baclofen tab 20 mg
generic
1
CARISOPRODOL TAB 250 MG
carisoprodol
BRAND
2
carisoprodol tab 350 mg
generic
1
chlorzoxazone tab 500 mg
generic
1
cyclobenzaprine hcl tab 10 mg
generic
1
QL
120 / 30 days
cyclobenzaprine hcl tab 5 mg
generic
1
QL
120 / 30 days
ed baclofen tab 10 mg
generic
1
FEXMID TAB 7.5 MG
cyclobenzaprine hcl
BRAND
2
LORZONE TAB 375 MG
chlorzoxazone
BRAND
2
LORZONE TAB 750 MG
chlorzoxazone
BRAND
2
metaxalone tab 800 mg
generic
1
methocarbamol tab 500 mg
generic
1
methocarbamol tab 750 mg
generic
1
PAGE 208
PRODUCT DESCRIPTION
BRAND/GEN
TIER
orphenadrine citrate er tab er 12h 100 mg
generic
1
SOMA TAB 250 MG
carisoprodol
BRAND
2
tizanidine hcl 2 mg
generic
1
tizanidine hcl 4 mg
generic
1
tizanidine hcl cap 2 mg
generic
1
generic
1
generic
1
tizanidine hcl tab 2 mg
generic
1
tizanidine hcl tab 4 mg
generic
1
EUFLEXXA SOLN PRSYR 20 MG/2ML
sodium hyaluronate (viscosupplement)
BRAND
4
PA
GEL-ONE PRSYR 30 MG/3ML
cross-linked hyaluronate
BRAND
4
PA
HYALGAN SOLN PRSYR 20 MG/2ML
BRAND
4
PA
HYALGAN SOLUTION 20 MG/2ML
BRAND
4
PA
ORTHOVISC SOLN PRSYR 30 MG/2ML
hyaluronan
BRAND
4
PA
SUPARTZ SOLN PRSYR 25 MG/2.5ML
BRAND
4
PA
SYNVISC ONE SOLN PRSYR 48 MG/6ML
hylan
BRAND
4
PA
SYNVISC SOLN PRSYR 16 MG/2ML
hylan
BRAND
4
PA
BRAND
3
azelastine hcl solution 0.15 %
generic
3
azelastine hcl solution 137 mcg/spray
generic
1
generic
1
*Viscosupplements**
*NASAL AGENTS - SYSTEMIC AND TOPICAL*
*Nasal Anti-infectives**
BACTROBAN NASAL OINTMENT 2 %
mupirocin calcium
*Nasal Antiallergy**
*Nasal Anticholinergics**
PAGE 209
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
1
FLUNISOLIDE SOLUTION 25 MCG/ACT
(0.025%)
flunisolide (nasal)
BRAND
2
flunisolide solution 25 mcg/act (0.025%)
generic
1
flunisolide solution 29 mcg/act (0.025%)
generic
1
fluticasone propionate suspension 50 mcg/act
generic
1
NASONEX SUSPENSION 50 MCG/ACT
mometasone furoate (nasal)
BRAND
2
RHINOCORT AQUA SUSPENSION 32
MCG/ACT
budesonide (nasal)
BRAND
2
triamcinolone acetonide aerosol 55 mcg/act
generic
1
TYZINE SOLUTION 0.05 %
tetrahydrozoline hcl
BRAND
3
TYZINE SOLUTION 0.1 %
tetrahydrozoline hcl
BRAND
3
generic
4
BOTOX RECON SOLN 100 UNIT
onabotulinumtoxina
BRAND
4
PA
BOTOX RECON SOLN 200 UNIT
onabotulinumtoxina
BRAND
4
PA
DYSPORT RECON SOLN 300 UNIT
abobotulinumtoxina
BRAND
4
PA
DYSPORT RECON SOLN 500 UNIT
abobotulinumtoxina
BRAND
4
PA
MYOBLOC SOLUTION 10000 UNIT/2ML
rimabotulinumtoxinb
BRAND
4
PA
MYOBLOC SOLUTION 2500 UNIT/0.5ML
rimabotulinumtoxinb
BRAND
4
PA
MYOBLOC SOLUTION 5000 UNIT/ML
rimabotulinumtoxinb
BRAND
4
PA
*Nasal Steroids**
*Sympathomimetic Decongestants**
*NEUROMUSCULAR AGENTS*
*ALS Agents**
riluzole tab 50 mg
*Neuromuscular Blocking Agent - Neurotoxins**
PAGE 210
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*NUTRIENTS*
*Proteins**
CLINIMIX E/DEXTROSE (5/20) SOLUTION 5
%
amino acid electrolyte w/ calcium infusion in
d20w
BRAND
2
CLINIMIX/DEXTROSE (2.75/5) SOLUTION
2.75 %
amino acid infusion in d5w
BRAND
2
4.25 %
BRAND
2
4.25 %
BRAND
2
4.25 %
BRAND
2
CLINIMIX/DEXTROSE (5/25) SOLUTION 5 %
BRAND
2
betaxolol hcl solution 0.5 %
generic
1
BETIMOL SOLUTION 0.25 %
timolol
BRAND
3
BETIMOL SOLUTION 0.5 %
timolol
BRAND
3
BETOPTIC-S SUSPENSION 0.25 %
betaxolol hcl (ophth)
BRAND
3
carteolol hcl solution 1 %
generic
1
COMBIGAN SOLUTION 0.2-0.5 %
brimonidine tartrate-timolol maleate
BRAND
3
COSOPT PF SOLUTION 22.3-6.8 MG/ML
dorzolamide hcl-timolol maleate
BRAND
3
dorzolamide hcl-timolol mal solution 22.3-6.8
mg/ml
generic
1
ISTALOL SOLUTION 0.5 %
timolol maleate (ophth)
BRAND
3
levobunolol hcl solution 0.25 %
generic
1
levobunolol hcl solution 0.5 %
generic
1
*OPHTHALMIC AGENTS*
*Beta-blockers - Ophthalmic**
PAGE 211
PRODUCT DESCRIPTION
BRAND/GEN
TIER
timolol maleate gel f soln 0.25 %
generic
1
timolol maleate gel f soln 0.5 %
generic
1
timolol maleate solution 0.25 %
generic
1
timolol maleate solution 0.5 %
generic
1
TIMOPTIC OCUDOSE SOLUTION 0.25 %
BRAND
3
TIMOPTIC OCUDOSE SOLUTION 0.5 %
BRAND
3
atropine sulfate solution 1 %
generic
1
atropine-care solution 1 %
generic
1
mydral solution 0.5 %
generic
1
mydral solution 1 %
generic
1
tropicamide solution 0.5 %
generic
1
tropicamide solution 1 %
generic
1
pilocarpine hcl solution 1 %
generic
1
generic
1
generic
1
EYLEA SOLUTION 2 MG/0.05ML
aflibercept
BRAND
4
PA
LUCENTIS SOLUTION 0.3 MG/0.05ML
ranibizumab
BRAND
4
PA
LUCENTIS SOLUTION 0.5 MG/0.05ML
ranibizumab
BRAND
4
PA
MACUGEN SOLUTION 0.3 MG
pegaptanib sodium
BRAND
4
PA
ALPHAGAN P SOLUTION 0.1 %
brimonidine tartrate
BRAND
3
apraclonidine hcl solution 0.5 %
generic
1
brimonidine tartrate solution 0.15 %
generic
1
brimonidine tartrate solution 0.2 %
generic
1
IOPIDINE SOLUTION 1 %
BRAND
3
*Cycloplegic Mydriatics**
*Miotics**
*Ophthalmic - Angiogenesis Inhibitors**
*Ophthalmic Adrenergic Agents**
PAGE 212
PRODUCT DESCRIPTION
BRAND/GEN
TIER
apraclonidine hcl
*Ophthalmic Anti-infectives**
AZASITE SOLUTION 1 %
azithromycin (ophth)
BRAND
3
BESIVANCE SUSPENSION 0.6 %
besifloxacin hcl
BRAND
3
ciprofloxacin hcl solution 0.3 %
generic
1
erythromycin ointment 5 mg/gm
generic
1
gatifloxacin solution 0.5 %
generic
1
gentak ointment 0.3 %
generic
1
gentamicin sulfate ointment 0.3 %
generic
1
gentamicin sulfate solution 0.3 %
generic
1
gentasol solution 0.3 %
generic
1
ilotycin ointment 5 mg/gm
generic
1
levofloxacin solution 0.5 %
generic
1
MITOSOL KIT 0.2 MG
mitomycin (ophthalmic)
BRAND
4
neo-polycin ointment 3.5-400-10000
generic
1
neomycin-bacitracin zn-polymyx ointment 5400-10000
generic
1
neomycin-polymyxin-gramicidin solution 1.7510000-.025
generic
1
ofloxacin solution 0.3 %
generic
1
romycin ointment 5 mg/gm
generic
1
sulfacetamide sodium ointment 10 %
generic
1
sulfacetamide sodium solution 10 %
generic
1
tobramycin solution 0.3 %
generic
1
tobrasol solution 0.3 %
generic
1
trifluridine solution 1 %
generic
1
triple antibiotic ointment 5-400-10000
generic
1
VIGAMOX SOLUTION 0.5 %
moxifloxacin hcl (ophth)
BRAND
2
BRAND
2
PA
*Ophthalmic Decongestants**
NAPHAZOLINE HCL SOLUTION 0.1 %
naphazoline hcl
PAGE 213
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Ophthalmic Immunomodulators**
RESTASIS EMULSION 0.05 %
cyclosporine (ophth)
BRAND
3
generic
1
BRAND
4
ALREX SUSPENSION 0.2 %
loteprednol etabonate
BRAND
3
bacitra-neomycin-polymyxin-hc ointment 1 %
generic
1
BLEPHAMIDE SUSPENSION 10-0.2 %
sulfacetamide sod-prednisolone
BRAND
3
dexamethasone sodium phosphate solution 0.1
%
generic
1
DUREZOL EMULSION 0.05 %
difluprednate
BRAND
3
FLAREX SUSPENSION 0.1 %
fluorometholone acetate
BRAND
3
fluorometholone suspension 0.1 %
generic
1
FML FORTE SUSPENSION 0.25 %
fluorometholone (ophth)
BRAND
3
FML OINTMENT 0.1 %
fluorometholone (ophth)
BRAND
3
LOTEMAX GEL 0.5 %
BRAND
2
LOTEMAX OINTMENT 0.5 %
BRAND
2
LOTEMAX SUSPENSION 0.5 %
BRAND
3
MAXIDEX SUSPENSION 0.1 %
dexamethasone (ophth)
BRAND
3
neo-polycin hc ointment 1 %
generic
1
neomycin-polymyxin-dexameth ointment 3.510000-0.1
generic
1
neomycin-polymyxin-dexameth suspension 3.510000-0.1
generic
1
*Ophthalmic Local Anesthetics**
proparacaine hcl solution 0.5 %
*Ophthalmic Photodynamic Therapy Agents**
VISUDYNE RECON SOLN 15 MG
verteporfin
PA
*Ophthalmic Steroids**
PAGE 214
PRODUCT DESCRIPTION
BRAND/GEN
TIER
neomycin-polymyxin-hc suspension 3.5-100001
generic
1
OZURDEX IMPLANT 0.7 MG
dexamethasone (ophth)
BRAND
4
poly-dex ointment 3.5-10000-0.1
generic
1
PRED MILD SUSPENSION 0.12 %
prednisolone acetate (ophth)
BRAND
3
prednisolone acetate suspension 1 %
generic
1
prednisolone sodium phosphate solution 1 %
generic
1
RETISERT IMPLANT 0.59 MG
fluocinolone acetonide (ophth)
BRAND
4
sulfacetamide-prednisolone solution 10-0.23 %
generic
1
SULFACETAMIDE-PREDNISOLONE
SUSPENSION 10-0.2 %
sulfacetamide sod-prednisolone
BRAND
3
TOBRADEX OINTMENT 0.3-0.1 %
tobramycin-dexamethasone
BRAND
2
tobramycin-dexamethasone suspension 0.3-0.1
%
generic
1
VEXOL SUSPENSION 1 %
rimexolone
BRAND
3
ALOCRIL SOLUTION 2 %
nedocromil sodium (ophth)
BRAND
3
PA
ALOMIDE SOLUTION 0.1 %
lodoxamide tromethamine
BRAND
3
PA
azelastine hcl solution 0.05 %
generic
1
BEPREVE SOLUTION 1.5 %
bepotastine besilate
BRAND
3
BROMDAY SOLUTION 0.09 %
bromfenac sodium (ophth)
BRAND
2
bromfenac sodium (once-daily) solution 0.09 %
generic
1
bromfenac sodium solution 0.09 %
generic
1
cromolyn sodium solution 4 %
generic
1
diclofenac sodium solution 0.1 %
generic
1
dorzolamide hcl solution 2 %
generic
1
EMADINE SOLUTION 0.05 %
emedastine difumarate
BRAND
3
*Ophthalmics - Misc.**
PAGE 215
PA
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
epinastine hcl solution 0.05 %
generic
1
flurbiprofen sodium solution 0.03 %
generic
1
ILEVRO SUSPENSION 0.3 %
nepafenac
BRAND
3
ketorolac tromethamine solution 0.4 %
generic
1
ketorolac tromethamine solution 0.5 %
generic
1
LASTACAFT SOLUTION 0.25 %
alcaftadine
BRAND
3
NEVANAC SUSPENSION 0.1 %
nepafenac
BRAND
3
PATADAY SOLUTION 0.2 %
olopatadine hcl
BRAND
3
PATANOL SOLUTION 0.1 %
olopatadine hcl
BRAND
3
latanoprost solution 0.005 %
generic
1
LUMIGAN SOLUTION 0.01 %
bimatoprost
BRAND
3
ST
LUMIGAN SOLUTION 0.03 %
bimatoprost
BRAND
3
ST
TRAVATAN Z SOLUTION 0.004 %
travoprost
BRAND
2
ST
ZIOPTAN SOLUTION 0.0015 %
tafluprost
BRAND
3
ST
generic
1
CETRAXAL SOLUTION 0.2 %
ciprofloxacin hcl (otic)
BRAND
2
ciprofloxacin hcl solution 0.2 %
generic
1
ofloxacin solution 0.3 %
generic
1
a/b otic solution 5.4-1.4 %
generic
1
antibiotic ear solution 3.5-10000-1
generic
1
antipyrine-benzocaine solution 5.4-1.4 %
generic
1
PA
PA
*Prostaglandins - Ophthalmic**
*OTIC AGENTS*
*Otic Agents - Miscellaneous**
acetic acid solution 2 %
*Otic Anti-infectives**
*Otic Combinations**
PAGE 216
PRODUCT DESCRIPTION
BRAND/GEN
TIER
antipyrine-benzocaine solution 5.5-1.4 %
generic
1
antipyrine-benzocaine solution 54-14 mg/ml
generic
1
aurax solution 5.5-1.4 %
generic
1
aurodex solution 5.4-1.4 %
generic
1
auroguard solution 54-14 mg/ml
generic
1
auroto solution 5.4-1.4 %
generic
1
CIPRO HC SUSPENSION 0.2-1 %
ciprofloxacin-hydrocortisone
BRAND
3
CIPRODEX SUSPENSION 0.3-0.1 %
ciprofloxacin-dexamethasone
BRAND
3
COLY-MYCIN S SUSPENSION 3.3-3-10-0.5
MG/ML
neomycin-colistin-hc-thonzonium
BRAND
3
CORTISPORIN-TC SUSPENSION 3.3-3-100.5 MG/ML
neomycin-colistin-hc-thonzonium
BRAND
3
cortomycin solution 3.5-10000-1
generic
1
cortomycin suspension 3.5-10000-1
generic
1
neomycin-polymyxin-hc solution 1 %
generic
1
neomycin-polymyxin-hc solution 3.5-10000-1
generic
1
neomycin-polymyxin-hc suspension 3.5-100001
generic
1
acetasol hc solution 2-1 %
generic
1
fluocinolone acetonide oil 0.01 %
generic
1
hydrocortisone-acetic acid solution 1-2 %
generic
1
BIVIGAM SOLUTION 10 GM/100ML
immune globulin (human) iv
BRAND
4
PA
BIVIGAM SOLUTION 5 GM/50ML
BRAND
4
PA
CARIMUNE NF RECON SOLN 12 GM
BRAND
4
PA
BRAND
4
PA
4
PA
*Otic Steroids**
*PASSIVE IMMUNIZING AGENTS*
*Immune Serums**
PAGE 217
PRODUCT DESCRIPTION
BRAND/GEN
BRAND
CYTOGAM INJECTABLE 50 MG/ML
cytomegalovirus immune globulin (human)
BRAND
4
FLEBOGAMMA DIF SOLUTION 0.5 GM/10ML
BRAND
4
PA
FLEBOGAMMA DIF SOLUTION 10 GM/100ML
BRAND
4
PA
BRAND
4
PA
FLEBOGAMMA DIF SOLUTION 2.5 GM/50ML
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
GAMASTAN S/D INJECTABLE
immune globulin (human)
BRAND
4
PA
GAMMAGARD S/D LESS IGA RECON SOLN
10 GM
BRAND
4
PA
GAMMAGARD S/D LESS IGA RECON SOLN
5 GM
BRAND
4
PA
GAMMAGARD S/D RECON SOLN 0.5 GM
BRAND
4
PA
GAMMAGARD S/D RECON SOLN 10 GM
BRAND
4
PA
GAMMAGARD S/D RECON SOLN 2.5 GM
BRAND
4
PA
GAMMAGARD S/D RECON SOLN 5 GM
BRAND
4
PA
GAMMAGARD SOLUTION 1 GM/10ML
immune globulin (human) iv or subcutaneous
BRAND
4
PA
BRAND
4
PA
GAMMAGARD SOLUTION 2.5 GM/25ML
BRAND
4
PA
PAGE 218
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
GAMMAKED SOLUTION 1 GM/10ML
BRAND
4
PA
BRAND
4
PA
GAMMAKED SOLUTION 2.5 GM/25ML
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
GAMMAPLEX SOLUTION 10 GM/200ML
BRAND
4
PA
GAMMAPLEX SOLUTION 2.5 GM/50ML
BRAND
4
PA
BRAND
4
BRAND
4
PA
GAMUNEX SOLUTION 1 GM/10ML
BRAND
4
PA
BRAND
4
PA
GAMUNEX SOLUTION 2.5 GM/25ML
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
GAMUNEX-C SOLUTION 1 GM/10ML
BRAND
4
PA
BRAND
4
PA
GAMUNEX-C SOLUTION 2.5 GM/25ML
BRAND
4
PA
PAGE 219
PRODUCT DESCRIPTION
BRAND/GEN
TIER
BRAND
4
PA
BRAND
4
PA
HEPAGAM B SOLUTION
hepatitis b immune globulin (human)
BRAND
4
PA
HIZENTRA 20% SOLUTION 1 GM/5ML
immune globulin (human) subcutaneous
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
HIZENTRA SOLUTION 10 GM/50ML
BRAND
4
PA
HYPERHEP B S/D SOLUTION
BRAND
4
PA
HYPERRAB S/D INJECTABLE 150 UNIT/ML
rabies immune globulin (human)
BRAND
2
PA
HYPERRHO S/D INJECTABLE 300 MCG
rho d immune globulin (human)
BRAND
4
PA
HYPERRHO S/D INJECTABLE 50 MCG
BRAND
4
PA
HYPERTET S/D INJECTABLE 250 UNIT/ML
tetanus immune globulin (human)
BRAND
2
PA
IMOGAM RABIES-HT INJECTABLE 150
UNIT/ML
rabies immune globulin (human)
BRAND
2
PA
MICRHOGAM ULTRA-FILTERED PLUS
INJECTABLE 50 MCG
BRAND
4
PA
NABI-HB SOLUTION
BRAND
4
PA
OCTAGAM SOLUTION 1 GM/20ML
BRAND
4
PA
BRAND
4
PA
OCTAGAM SOLUTION 2.5 GM/50ML
BRAND
4
PA
BRAND
4
PA
PAGE 220
PRODUCT DESCRIPTION
BRAND/GEN
TIER
BRAND
4
PA
PRIVIGEN SOLUTION 10 GM/100ML
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
RHOGAM ULTRA-FILTERED PLUS
INJECTABLE 300 MCG
BRAND
4
PA
RHOPHYLAC SOLUTION 1500 UNIT/2ML
BRAND
4
PA
VIVAGLOBIN SOLUTION 160 MG/ML
BRAND
4
PA
WINRHO SDF SOLUTION 1500 UNIT/1.3ML
BRAND
4
PA
WINRHO SDF SOLUTION 15000 UNIT/13ML
BRAND
4
PA
BRAND
4
PA
BRAND
4
PA
SYNAGIS SOLUTION 100 MG/ML
palivizumab
BRAND
4
PA
SYNAGIS SOLUTION 50 MG/0.5ML
palivizumab
BRAND
4
PA
amoxicillin 250 mg
generic
1
amoxicillin cap 250 mg
generic
1
amoxicillin cap 500 mg
generic
1
amoxicillin chew tab 125 mg
generic
1
amoxicillin chew tab 250 mg
generic
1
AMOXICILLIN CHEW TAB 250 MG
BRAND
2
*Monoclonal Antibodies**
*PENICILLINS*
*Aminopenicillins**
PAGE 221
PRODUCT DESCRIPTION
BRAND/GEN
TIER
amoxicillin
amoxicillin recon susp 125 mg/5ml
generic
1
generic
1
generic
1
generic
1
amoxicillin tab 500 mg
generic
1
amoxicillin tab 875 mg
generic
1
ampicillin cap 250 mg
generic
1
ampicillin cap 500 mg
generic
1
ampicillin recon susp 125 mg/5ml
generic
1
ampicillin recon susp 250 mg/5ml
generic
1
ampicillin sodium recon soln 1 gm
generic
1
PA
generic
1
PA
AMPICILLIN SODIUM RECON SOLN 10 GM
ampicillin sodium
BRAND
2
PA
ampicillin sodium recon soln 125 mg
generic
1
PA
generic
1
PA
generic
1
PA
generic
1
PA
BICILLIN L-A SUSPENSION 1200000
UNIT/2ML
penicillin g benzathine
BRAND
3
PA
BICILLIN L-A SUSPENSION 2400000
UNIT/4ML
BRAND
3
PA
BICILLIN L-A SUSPENSION 600000 UNIT/ML
BRAND
3
PA
penicillin g pot in dextrose solution 20000
unit/ml
generic
1
PA
unit/ml
generic
1
PA
unit/ml
generic
1
PA
penicillin g potassium recon soln 20000000 unit
generic
1
PA
*Natural Penicillins**
PAGE 222
PRODUCT DESCRIPTION
BRAND/GEN
TIER
penicillin g potassium recon soln 5000000 unit
generic
1
PA
PENICILLIN G PROCAINE SUSPENSION
600000 UNIT/ML
penicillin g procaine
BRAND
2
PA
penicillin g sodium recon soln 5000000 unit
generic
1
PA
penicillin v potassium recon soln 125 mg/5ml
generic
1
penicillin v potassium recon soln 250 mg/5ml
generic
1
penicillin v potassium tab 250 mg
generic
1
penicillin v potassium tab 500 mg
generic
1
pfizerpen-g recon soln 5000000 unit
generic
1
amoxicillin-pot clavulanate chew tab 200-28.5
mg
generic
1
amoxicillin-pot clavulanate chew tab 400-57 mg
generic
1
amoxicillin-pot clavulanate er tab er 12h 100062.5 mg
generic
1
amoxicillin-pot clavulanate recon susp 200-28.5
mg/5ml
generic
1
mg/5ml
generic
1
amoxicillin-pot clavulanate recon susp 400-57
mg/5ml
generic
1
mg/5ml
generic
1
amoxicillin-pot clavulanate tab 250-125 mg
generic
1
generic
1
generic
1
ampicillin-sulbactam sodium recon soln 1.5 (10.5) gm
generic
1
PA
BICILLIN C-R 900/300 SUSPENSION 900000300000 UNIT/2ML
penicillin g benzathine & procaine
BRAND
3
PA
BICILLIN C-R SUSPENSION 1200000
UNIT/2ML
penicillin g benzathine & procaine
BRAND
3
PA
TIMENTIN RECON SOLN 3.1 GM
BRAND
3
PA
PA
*Penicillin Combinations**
PAGE 223
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ticarcillin & pot clavulanate
*PHARMACEUTICAL ADJUVANTS*
*Liquid Vehicles**
sterile diluent/epoprostenol solution
generic
4
MAKENA OIL 250 MG/ML
hydroxyprogesterone caproate
BRAND
4
medroxyprogesterone acetate tab 10 mg
generic
1
medroxyprogesterone acetate tab 2.5 mg
generic
1
medroxyprogesterone acetate tab 5 mg
generic
1
MEGACE ES SUSPENSION 625 MG/5ML
megestrol acetate (appetite)
BRAND
3
norethindrone acetate tab 5 mg
generic
1
progesterone micronized cap 100 mg
generic
1
progesterone micronized cap 200 mg
generic
1
*PROGESTINS*
*Progestins**
PA
*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*
*Agents for Chemical Dependency**
acamprosate calcium tab dr 333 mg
generic
3
CAMPRAL DOSE PAK TAB DR 333 MG
acamprosate calcium
BRAND
3
CAMPRAL TAB DR 333 MG
acamprosate calcium
BRAND
3
disulfiram tab 250 mg
generic
1
disulfiram tab 500 mg
generic
1
BRAND
4
*Anti-Cataplectic Agents**
XYREM SOLUTION 500 MG/ML
sodium oxybate
PA
MPL
3 / 30 days
*Antidementia Agents**
donepezil hcl tab 10 mg
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
1
PAGE 224
PRODUCT DESCRIPTION
BRAND/GEN
donepezil hcl tab disp 10 mg
generic
donepezil hcl tab disp 5 mg
generic
EXELON PATCH 24HR 13.3 MG/24HR
rivastigmine
TIER
QL
30 / 30 days
1
QL
30 / 30 days
BRAND
3
PA
rivastigmine
BRAND
3
PA
rivastigmine
BRAND
3
PA
EXELON SOLUTION 2 MG/ML
rivastigmine tartrate
BRAND
3
galantamine hydrobromide er cap er 24h 16 mg
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
generic
1
QL
30 / 30 days
galantamine hydrobromide solution 4 mg/ml
generic
1
galantamine hydrobromide tab 12 mg
generic
1
QL
60 / 30 days
generic
1
QL
60 / 30 days
generic
1
QL
60 / 30 days
NAMENDA SOLUTION 10 MG/5ML
memantine hcl
BRAND
3
PA
NAMENDA TAB 10 MG
memantine hcl
BRAND
3
QL
60 / 30 days
NAMENDA TAB 5 MG
memantine hcl
BRAND
3
QL
60 / 30 days
NAMENDA TITRATION PAK TAB 5 (28)-10
(21) MG
memantine hcl
BRAND
2
NAMENDA XR CAP ER 24H 14 MG
memantine hcl
BRAND
3
PA
memantine hcl
BRAND
3
PA
memantine hcl
BRAND
3
PA
memantine hcl
BRAND
3
PA
rivastigmine tartrate cap 1.5 mg
generic
1
QL
60 / 30 days
rivastigmine tartrate cap 3 mg
generic
1
QL
60 / 30 days
PAGE 225
PRODUCT DESCRIPTION
BRAND/GEN
TIER
rivastigmine tartrate cap 4.5 mg
generic
1
QL
60 / 30 days
rivastigmine tartrate cap 6 mg
generic
1
QL
60 / 30 days
duo-vil 2-10 tab 2-10 mg
generic
3
duo-vil 2-25 tab 2-25 mg
generic
3
perphenazine-amitriptyline tab 2-10 mg
generic
3
generic
3
generic
3
generic
3
generic
3
SAVELLA TAB 100 MG
milnacipran hcl
BRAND
3
PA
SAVELLA TAB 12.5 MG
milnacipran hcl
BRAND
3
PA
SAVELLA TAB 25 MG
milnacipran hcl
BRAND
3
PA
SAVELLA TAB 50 MG
milnacipran hcl
BRAND
3
PA
SAVELLA TITRATION PACK MISC 12.5 & 25
& 50 MG
milnacipran hcl
BRAND
2
XENAZINE TAB 12.5 MG
tetrabenazine
BRAND
4
PA
XENAZINE TAB 25 MG
tetrabenazine
BRAND
4
PA
AMPYRA TAB ER 12H 10 MG
dalfampridine
BRAND
4
PA
AUBAGIO TAB 14 MG
teriflunomide
BRAND
4
PA
AUBAGIO TAB 7 MG
teriflunomide
BRAND
4
PA
AVONEX KIT 30 MCG
interferon beta-1a
BRAND
4
PA
*Combination Psychotherapeutics**
*Fibromyalgia Agents**
*Movement Disorder Drug Therapy**
*Multiple Sclerosis Agents**
4
PAGE 226
PRODUCT DESCRIPTION
BRAND/GEN
TIER
AVONEX PEN KIT 30 MCG/0.5ML
interferon beta-1a
BRAND
AVONEX PREFILLED KIT 30 MCG/0.5ML
interferon beta-1a
BRAND
4
BETASERON KIT 0.3 MG
interferon beta-1b
BRAND
4
PA
COPAXONE KIT 20 MG/ML
glatiramer acetate
BRAND
4
PA
COPAXONE SOLN PRSYR 40 MG/ML
glatiramer acetate
BRAND
4
EXTAVIA KIT 0.3 MG
interferon beta-1b
BRAND
4
PA
GILENYA CAP 0.5 MG
fingolimod hcl
BRAND
4
PA
REBIF REBIDOSE SOLUTION 22 MCG/0.5ML
interferon beta-1a
BRAND
4
REBIF REBIDOSE SOLUTION 44 MCG/0.5ML
interferon beta-1a
BRAND
4
REBIF REBIDOSE TITRATION PACK
SOLUTION 6X8.8 & 6X22 MCG
interferon beta-1a
BRAND
4
PA
REBIF SOLUTION 22 MCG/0.5ML
interferon beta-1a
BRAND
4
PA
REBIF SOLUTION 44 MCG/0.5ML
interferon beta-1a
BRAND
4
PA
REBIF TITRATION PACK SOLUTION 6X8.8 &
6X22 MCG
interferon beta-1a
BRAND
4
PA
TECFIDERA CAP DR 120 MG
dimethyl fumarate
BRAND
4
PA
TECFIDERA CAP DR 240 MG
dimethyl fumarate
BRAND
4
PA
TECFIDERA MISC 120 & 240 MG
dimethyl fumarate
BRAND
4
PA
TYSABRI CONC 300 MG/15ML
natalizumab
BRAND
4
PA
GRALISE TAB 300 MG
gabapentin (phn)
BRAND
3
GRALISE TAB 600 MG
gabapentin (phn)
BRAND
3
*Postherpetic Neuralgia (PHN) Agents**
PAGE 227
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Pseudobulbar Affect (PBA) Agents**
NUEDEXTA CAP 20-10 MG
dextromethorphan hbr-quinidine sulfate
BRAND
3
*Psychotherapeutic and Neurological Agents - Misc.**
ergoloid mesylates tab 1 mg
generic
1
ORAP TAB 1 MG
pimozide
BRAND
3
ORAP TAB 2 MG
pimozide
BRAND
3
HORIZANT TAB ER 300 MG
gabapentin enacarbil
BRAND
2
HORIZANT TAB ER 600 MG
gabapentin enacarbil
BRAND
2
buproban tab er 12h 150 mg
generic
0
QL
90 / 365 days
bupropion hcl er (smoking det) tab er 12h 150
mg
generic
0
QL
90 / 365 days
CHANTIX CONTINUING MONTH PAK TAB 1
MG
varenicline tartrate
BRAND
0
QL
90 / 365 days
CHANTIX STARTING MONTH PAK TAB 0.5
MG X 11 & 1 MG X 42
BRAND
0
CHANTIX TAB 0.5 MG
BRAND
0
QL
90 / 365 days
CHANTIX TAB 1 MG
BRAND
0
QL
90 / 365 days
nicotine patch 24hr 14 mg/24hr
generic
0
QL
90 / 365 days
generic
0
QL
90 / 365 days
generic
0
QL
90 / 365 days
NICOTROL INHALER 10 MG
nicotine
BRAND
0
QL
90 / 365 days
NICOTROL NS SOLUTION 10 MG/ML
nicotine
BRAND
0
QL
90 / 365 days
*Restless Leg Syndrome (RLS) Agents**
*Smoking Deterrents**
*RESPIRATORY AGENTS - MISC.*
*Alpha-Proteinase Inhibitor (Human)**
PAGE 228
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ARALAST NP RECON SOLN 1000 MG
alpha1-proteinase inhibitor (human)
BRAND
4
PA
ARALAST NP RECON SOLN 500 MG
alpha1-proteinase inhibitor (human)
BRAND
4
PA
KALYDECO TAB 150 MG
ivacaftor
BRAND
4
PA
PULMOZYME SOLUTION 1 MG/ML
dornase alfa
BRAND
4
PA
generic
1
avidoxy tab 100 mg
generic
1
demeclocycline hcl tab 150 mg
generic
1
demeclocycline hcl tab 300 mg
generic
1
doxy 100 recon soln 100 mg
generic
1
PA
doxycycline hyclate cap 100 mg
generic
1
PA
doxycycline hyclate cap 50 mg
generic
1
doxycycline hyclate recon soln 100 mg
generic
1
PA
doxycycline hyclate tab 100 mg
generic
1
PA
doxycycline hyclate tab 20 mg
generic
1
doxycycline hyclate tab dr 100 mg
generic
1
generic
1
generic
1
doxycycline monohydrate cap 100 mg
generic
1
generic
1
generic
1
generic
1
doxycycline monohydrate tab 100 mg
generic
1
generic
1
generic
1
*Cystic Fibrosis Agents**
*SULFONAMIDES*
*Sulfonamides**
sulfadiazine tab 500 mg
*TETRACYCLINES*
*Tetracyclines**
PAGE 229
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
1
minocycline hcl cap 100 mg
generic
1
generic
1
generic
1
minocycline hcl tab 100 mg
generic
1
generic
1
generic
1
morgidox cap 100 mg
generic
1
TETRACYCLINE HCL CAP 250 MG
tetracycline hcl
BRAND
2
TETRACYCLINE HCL CAP 500 MG
tetracycline hcl
BRAND
2
VIBRAMYCIN SYRUP 50 MG/5ML
doxycycline calcium
BRAND
3
methimazole tab 10 mg
generic
1
methimazole tab 5 mg
generic
1
propylthiouracil tab 50 mg
generic
1
armour thyroid tab 120 mg
generic
1
ARMOUR THYROID TAB 180 MG
thyroid
BRAND
2
thyroid
BRAND
2
thyroid
BRAND
2
levothroid tab 100 mcg
generic
1
generic
1
generic
1
generic
1
generic
1
generic
1
generic
1
*THYROID AGENTS*
*Antithyroid Agents**
*Thyroid Hormones**
1
PAGE 230
PRODUCT DESCRIPTION
BRAND/GEN
generic
generic
1
generic
1
generic
1
generic
1
levothyroxine sodium recon soln 100 mcg
generic
1
generic
1
generic
1
levothyroxine sodium tab 100 mcg
generic
1
generic
1
generic
1
generic
1
generic
1
generic
1
generic
1
generic
1
generic
1
generic
1
generic
1
generic
1
levoxyl tab 100 mcg
generic
1
levoxyl tab 112 mcg
generic
1
levoxyl tab 125 mcg
generic
1
levoxyl tab 137 mcg
generic
1
levoxyl tab 150 mcg
generic
1
levoxyl tab 175 mcg
generic
1
levoxyl tab 200 mcg
generic
1
levoxyl tab 25 mcg
generic
1
levoxyl tab 50 mcg
generic
1
levoxyl tab 75 mcg
generic
1
levoxyl tab 88 mcg
generic
1
liothyronine sodium tab 25 mcg
generic
1
PAGE 231
TIER
PA
PRODUCT DESCRIPTION
BRAND/GEN
generic
1
generic
1
NATURE-THROID TAB 113.75 MG
thyroid
BRAND
1
NATURE-THROID TAB 130 MG
thyroid
BRAND
1
thyroid
BRAND
1
thyroid
BRAND
1
thyroid
BRAND
1
thyroid
BRAND
1
thyroid
BRAND
1
thyroid
BRAND
1
thyroid
BRAND
1
thyroid
BRAND
1
thyroid
BRAND
1
thyroid
BRAND
1
thyroid
BRAND
1
np thyroid tab 30 mg
generic
1
generic
1
generic
1
unithroid tab 100 mcg
generic
1
generic
1
generic
1
generic
1
generic
1
generic
1
generic
1
PAGE 232
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
1
generic
1
generic
1
generic
1
generic
1
WESTHROID TAB 162.5 MG
thyroid
BRAND
2
WESTHROID TAB 325 MG
thyroid
BRAND
2
WESTHROID TAB 48.75 MG
thyroid
BRAND
2
WESTHROID TAB 65 MG
thyroid
BRAND
2
WESTHROID-P TAB 48.75 MG
thyroid
BRAND
2
WESTHROID-P TAB 65 MG
thyroid
BRAND
2
WP THYROID TAB 48.75 MG
thyroid
BRAND
2
WP THYROID TAB 65 MG
thyroid
BRAND
2
ADACEL SUSPENSION 5-2-15.5 LF-MCG/0.5
tetanus toxoid-diphtheria-acellular pertussis
adsorb (tdap)
BRAND
0
BOOSTRIX SUSPENSION 5-2.5-18.5
tetanus toxoid-diphtheria-acellular pertussis
adsorb (tdap)
BRAND
0
DAPTACEL SUSPENSION 10-15-5
diphtheria, acellular pertussis & tetanus toxoids
BRAND
0
DECAVAC INJECTABLE 5-2 LFU
tetanus-diphtheria toxoids (td)
BRAND
0
DIPHTHERIA-TETANUS TOXOIDS DT
SUSPENSION 25-5 LFU/0.5ML
diphtheria-tetanus toxoids (dt)
BRAND
0
DIPHTHERIA-TETANUS TOXOIDS
INJECTABLE 6.7-5 LFU/0.5ML
diphtheria-tetanus toxoids (dt)
BRAND
0
*TOXOIDS*
*Toxoid Combinations**
0
PAGE 233
PRODUCT DESCRIPTION
BRAND/GEN
TIER
INFANRIX SUSPENSION 25-58-10
BRAND
KINRIX SUSPENSION
diph-tetanus tox ad-acell pertussis & polio
virus, ipv vac
BRAND
0
AL
Up to 18 yrs old
PEDIARIX SUSPENSION
diph-tetanus tox-acell pert-hepatitis b recombpolio ipv vac
BRAND
0
AL
Up to 18 yrs old
PENTACEL RECON SUSP
diph-ac pert-tet tox ad-polio ipv-haemophil b
poly vac
BRAND
0
AL
Up to 18 yrs old
TENIVAC INJECTABLE 5-2 LFU
BRAND
0
tetanus-diphtheria toxoids td suspension 2-2
lf/0.5ml
generic
0
TETANUS-DIPHTHERIA TOXOIDS TD
SUSPENSION 2-2 LF/0.5ML
BRAND
0
TRIHIBIT PRESERVATIVE FREE KIT 46.8-6.7
MCG-LFU
diph, acellular pertussis, tetanus tox &
haemophilus b poly
BRAND
0
AL
Up to 18 yrs old
TRIPEDIA PRESERVATIVE FREE
SUSPENSION 46.8-6.7-5
BRAND
0
BRAND
0
CUVPOSA SOLUTION 1 MG/5ML
glycopyrrolate
BRAND
3
dicyclomine hcl cap 10 mg
generic
1
dicyclomine hcl solution 10 mg/5ml
generic
1
dicyclomine hcl tab 20 mg
generic
1
GLYCATE TAB 1.5 MG
glycopyrrolate
BRAND
3
glycopyrrolate tab 1 mg
generic
1
glycopyrrolate tab 2 mg
generic
1
*Toxoids**
TETANUS TOXOID ADSORBED SOLUTION 5
LFU
tetanus toxoid adsorbed
*ULCER DRUGS*
*Antispasmodics**
PAGE 234
PRODUCT DESCRIPTION
BRAND/GEN
TIER
hyomax tab 0.125 mg
generic
1
hyomax-sl sl tab 0.125 mg
generic
1
hyomax-sr tab er 12h 0.375 mg
generic
1
hyoscyamine sulfate elixir 0.125 mg/5ml
generic
1
hyoscyamine sulfate er tab er 12h 0.375 mg
generic
1
hyoscyamine sulfate sl tab 0.125 mg
generic
1
hyoscyamine sulfate tab 0.125 mg
generic
1
hyoscyamine sulfate tab disp 0.125 mg
generic
1
hyosyne elixir 0.125 mg/5ml
generic
1
methscopolamine bromide tab 2.5 mg
generic
1
methscopolamine bromide tab 5 mg
generic
1
oscimin sl tab 0.125 mg
generic
1
oscimin sr tab er 12h 0.375 mg
generic
1
oscimin tab 0.125 mg
generic
1
oscimin tab disp 0.125 mg
generic
1
SAL-TROPINE TAB 0.4 MG
atropine sulfate
BRAND
2
scopolamine hbr solution 0.4 mg/ml
generic
1
symax-sl sl tab 0.125 mg
generic
1
symax-sr tab er 12h 0.375 mg
generic
1
cimetidine tab 200 mg
generic
1
generic
1
generic
1
generic
1
famotidine recon susp 40 mg/5ml
generic
1
famotidine tab 20 mg
generic
1
famotidine tab 40 mg
generic
1
nizatidine cap 150 mg
generic
1
nizatidine cap 300 mg
generic
1
nizatidine solution 15 mg/ml
generic
1
ranitidine hcl 150 mg
generic
1
PA
*H-2 Antagonists**
1
PAGE 235
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ranitidine hcl cap 150 mg
generic
ranitidine hcl cap 300 mg
generic
1
ranitidine hcl tab 150 mg
generic
1
ranitidine hcl tab 300 mg
generic
1
carafate suspension 1 gm/10ml
generic
1
sucralfate suspension 1 gm/10ml
generic
1
sucralfate tab 1 gm
generic
1
ACIPHEX TAB DR 20 MG
rabeprazole sodium
BRAND
3
DEXILANT CAP DR 30 MG
dexlansoprazole
BRAND
DEXILANT CAP DR 60 MG
dexlansoprazole
BRAND
FIRST-LANSOPRAZOLE SUSPENSION 3
MG/ML
lansoprazole
BRAND
2
FIRST-OMEPRAZOLE SUSPENSION 2
MG/ML
omeprazole
BRAND
2
lansoprazole cap dr 15 mg
generic
1
QL
30 / 30 days
lansoprazole cap dr 30 mg
generic
1
QL
30 / 30 days
lansoprazole tab disp 15 mg
generic
1
QL
30 / 30 days
lansoprazole tab disp 30 mg
generic
1
QL
30 / 30 days
NEXIUM CAP DR 20 MG
esomeprazole magnesium
QL
BRAND
30 / 30 days
3
NEXIUM CAP DR 40 MG
BRAND
NEXIUM PACKET 10 MG
BRAND
2
NEXIUM PACKET 2.5 MG
BRAND
2
*Misc. Anti-Ulcer**
*Proton Pump Inhibitors**
QL
30 / 30 days
ST
QL
30 / 30 days
3
ST
QL
30 / 30 days
3
ST
ST
QL
30 / 30 days
3
ST
2
PAGE 236
PRODUCT DESCRIPTION
BRAND/GEN
TIER
NEXIUM PACKET 20 MG
BRAND
NEXIUM PACKET 40 MG
BRAND
NEXIUM PACKET 5 MG
BRAND
2
omeprazole cap dr 10 mg
generic
1
QL
60 / 30 days
generic
1
QL
60 / 30 days
generic
1
QL
60 / 30 days
OMEPRAZOLE+SYRSPEND SF ALKA
SUSPENSION 2 MG/ML
omeprazole
BRAND
2
pantoprazole sodium recon soln 40 mg
generic
1
QL
30 / 30 days
pantoprazole sodium tab dr 20 mg
generic
1
QL
30 / 30 days
pantoprazole sodium tab dr 40 mg
generic
1
QL
30 / 30 days
QL
rabeprazole sodium tab dr 20 mg
generic
30 / 30 days
3
QL
30 / 30 days
ST
QL
30 / 30 days
2
ST
ST
*Ulcer Drugs - Prostaglandins**
misoprostol tab 100 mcg
generic
1
misoprostol tab 200 mcg
generic
1
methenamine hippurate tab 1 gm
generic
1
methenamine mandelate tab 0.5 gm
generic
1
methenamine mandelate tab 1 gm
generic
1
MONUROL PACKET 3 GM
fosfomycin tromethamine
BRAND
3
nitrofurantoin macrocrystal cap 100 mg
generic
1
nitrofurantoin macrocrystal cap 50 mg
generic
1
nitrofurantoin monohyd macro cap 100 mg
generic
1
*URINARY ANTI-INFECTIVES*
*Urinary Anti-infectives**
*URINARY ANTISPASMODICS*
*Urinary Antispasmodic - Antimuscarinics (Anticholinergic)**
PAGE 237
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ENABLEX TAB ER 24H 15 MG
darifenacin hydrobromide
BRAND
3
ST
ENABLEX TAB ER 24H 7.5 MG
darifenacin hydrobromide
BRAND
3
ST
oxybutynin chloride er tab er 24h 10 mg
generic
1
generic
1
generic
1
oxybutynin chloride syrup 5 mg/5ml
generic
1
oxybutynin chloride tab 5 mg
generic
1
tolterodine tartrate er cap er 24h 2 mg
generic
1
ST
tolterodine tartrate er cap er 24h 4 mg
generic
1
ST
tolterodine tartrate tab 1 mg
generic
1
tolterodine tartrate tab 2 mg
generic
1
TOVIAZ TAB ER 24H 4 MG
fesoterodine fumarate
BRAND
3
ST
TOVIAZ TAB ER 24H 8 MG
fesoterodine fumarate
BRAND
3
ST
trospium chloride er cap er 24h 60 mg
generic
1
trospium chloride tab 20 mg
generic
1
VESICARE TAB 10 MG
solifenacin succinate
BRAND
2
ST
VESICARE TAB 5 MG
solifenacin succinate
BRAND
2
ST
bethanechol chloride tab 10 mg
generic
1
generic
1
generic
1
generic
1
*Urinary Antispasmodics - Cholinergic Agonists**
*Urinary Antispasmodics - Direct Muscle Relaxants**
flavoxate hcl tab 100 mg
generic
1
BRAND
0
*VACCINES*
*Bacterial Vaccines**
ACTHIB RECON SOLN
haemophilus b polysac conj vac
AL
Up to 18 yrs old
0
PAGE 238
PRODUCT DESCRIPTION
BRAND/GEN
TIER
HIBERIX RECON SOLN 10 MCG
BRAND
MENACTRA INJECTABLE
meningococcal (a,c,y&w-135) polysaccharide
conjugate vaccine
BRAND
0
MENHIBRIX RECON SOLN 5-5-2.5 MCG
meningococcal (c & y)-haemophilus b tetanus
tox conj vaccine
BRAND
0
MENOMUNE INJECTABLE
meningococcal vac a,c,y&w-135
BRAND
0
MENVEO RECON SOLN
meningococcal (a,c,y&w-135) oligosaccharide
conjugate vac
BRAND
0
PEDVAX HIB SUSPENSION 7.5 MCG/0.5ML
BRAND
PNEUMOVAX 23 INJECTABLE 25
MCG/0.5ML
pneumococcal vac polyvalent
PREVNAR 13 SUSPENSION
pneumococcal 13-valent conjugate vaccine
AL
Up to 18 yrs old
AL
Up to 18 yrs old
0
AL
Up to 18 yrs old
BRAND
0
AL
19 to 999 yrs old
BRAND
0
AL
19 to 999 yrs old
BRAND
0
AL
Up to 18 yrs old
AFLURIA PRESERVATIVE FREE
SUSPENSION
influenza virus vaccine split preservative free
BRAND
0
AFLURIA SUSPENSION
influenza virus vaccine split
BRAND
0
AGRIFLU SUSPENSION
influenza virus vaccine types a & b preservative
free
BRAND
0
ENGERIX-B INJECTABLE 20 MCG/ML
hepatitis b vaccine (recomb)
BRAND
0
ENGERIX-B SUSPENSION 10 MCG/0.5ML
BRAND
0
ENGERIX-B SUSPENSION 20 MCG/ML
BRAND
0
FLUARIX QUADRIVALENT SUSPENSION 0.5
ML
influenza virus vaccine split quadrivalent
BRAND
0
*Mixed Vaccine Combinations**
COMVAX SUSPENSION 7.5-5 MCG/0.5ML
haemophilus b polysac conj-hepatitis b
(recomb) vaccines
*Viral Vaccines**
PAGE 239
PRODUCT DESCRIPTION
BRAND/GEN
TIER
FLUARIX SUSPENSION
BRAND
0
FLUBLOK SOLUTION
influenza virus vaccine recombinant
hemagglutinin (ha)
BRAND
0
FLUCELVAX SUSPENSION
influenza virus vaccine tissue-cultured subunit
BRAND
0
FLULAVAL INJECTABLE
BRAND
0
FLULAVAL QUADRIVALENT SUSPENSION
BRAND
0
FLULAVAL QUADRIVALENT SUSPENSION
0.5 ML
BRAND
0
FLUMIST LIQUID
influenza virus vaccine live
BRAND
0
FLUMIST QUADRIVALENT SUSPENSION
influenza virus vaccine live quadrivalent
BRAND
0
FLUVIRIN INJECTABLE
influenza virus vaccine types a & b surface
antigen
BRAND
0
FLUVIRIN PRESERVATIVE FREE
SUSPENSION
free
BRAND
0
FLUZONE DEVICE 9 MCG/STRAIN
BRAND
0
FLUZONE HIGH-DOSE SUSPENSION
influenza virus vaccine split high-dose
preservative free
BRAND
0
FLUZONE INJECTABLE
BRAND
0
FLUZONE PEDIATRIC PF SUSPENSION
BRAND
0
FLUZONE PRESERVATIVE FREE
SUSPENSION
BRAND
0
FLUZONE QUADRIVALENT SUSPENSION
BRAND
0
0.25 ML
BRAND
0
0
PAGE 240
PRODUCT DESCRIPTION
BRAND/GEN
TIER
0.5 ML
BRAND
GARDASIL SUSPENSION
human papillomavirus (hpv) quadrivalent
recombinant vaccine
BRAND
0
HAVRIX SUSPENSION 1440 EL U/ML
hepatitis a vaccine
BRAND
0
HAVRIX SUSPENSION 720 EL U/0.5ML
hepatitis a vaccine
BRAND
0
IPOL INJECTABLE
poliovirus vaccine, ipv
BRAND
0
M-M-R II INJECTABLE
measles, mumps & rubella virus vaccines
BRAND
0
MEDICAL PROVIDER EZ FLU PF KIT
free
BRAND
0
MEDICAL PROVIDER EZ FLU SHOT KIT 0.5
ML
BRAND
0
PHYSICIANS EZ USE FLU KIT
influenza virus vaccine types a & b surface
antigen
BRAND
0
PROQUAD INJECTABLE
measles-mumps-rubella-varicella virus
vaccines
BRAND
0
RECOMBIVAX HB SUSPENSION 10 MCG/ML
BRAND
0
RECOMBIVAX HB SUSPENSION 40 MCG/ML
BRAND
0
RECOMBIVAX HB SUSPENSION 5
MCG/0.5ML
BRAND
0
ROTARIX RECON SUSP
rotavirus vaccine, live oral
BRAND
ROTATEQ SOLUTION
rotavirus vaccine, live oral pentavalent
GL
Female
AL
Up to 18 yrs old
0
AL
Up to 18 yrs old
BRAND
0
AL
Up to 18 yrs old
TWINRIX SUSPENSION 720-20
hepatitis a (inactivated)-hepatitis b
(recombinant) vaccines
BRAND
0
VAQTA SUSPENSION 25 UNIT/0.5ML
hepatitis a vaccine
BRAND
0
0
PAGE 241
PRODUCT DESCRIPTION
BRAND/GEN
TIER
VAQTA SUSPENSION 50 UNIT/ML
hepatitis a vaccine
BRAND
VARIVAX INJECTABLE 1350 PFU/0.5ML
varicella virus vaccine live
BRAND
0
ZOSTAVAX RECON SOLN 19400
UNT/0.65ML
zoster vaccine live
BRAND
0
clindamycin phosphate cream 2 %
generic
1
GYNAZOLE-1 CREAM 2 %
butoconazole nitrate (one dose)
BRAND
2
miconazole 3 kit 200-2 mg-% (9gm)
generic
1
MICONAZOLE 3 SUPPOS 200 MG
miconazole nitrate vaginal
BRAND
2
NYSTATIN TAB 100000 UNIT
nystatin vaginal
BRAND
2
terconazole cream 0.4 %
generic
1
terconazole cream 0.8 %
generic
1
terconazole suppos 80 mg
generic
1
zazole cream 0.4 %
generic
1
zazole cream 0.8 %
generic
1
ESTRACE CREAM 0.1 MG/GM
estradiol vaginal
BRAND
2
ESTRING RING 2 MG
estradiol vaginal
BRAND
3
FEMRING RING 0.05 MG/24HR
estradiol acetate vaginal
BRAND
3
FEMRING RING 0.1 MG/24HR
estradiol acetate vaginal
BRAND
3
PREMARIN CREAM 0.625 MG/GM
estrogens, conjugated vaginal
BRAND
2
CRINONE GEL 4 %
progesterone (vaginal)
BRAND
3
CRINONE GEL 8 %
BRAND
3
AL
19 to 999 yrs old
*VAGINAL PRODUCTS*
*Vaginal Anti-infectives**
*Vaginal Estrogens**
*Vaginal Progestins**
PAGE 242
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ENDOMETRIN INSERT 100 MG
BRAND
3
FIRST-PROGESTERONE VGS 100 SUPPOS
100 MG
BRAND
3
200 MG
BRAND
2
25 MG
BRAND
3
400 MG
BRAND
3
50 MG
BRAND
3
PROCHIEVE GEL 4 %
BRAND
3
PROCHIEVE GEL 8 %
BRAND
3
ADRENACLICK SOLN A-INJ 0.15 MG/0.15ML
epinephrine
BRAND
2
QL
1 / 30 days
adrenaclick soln a-inj 0.3 mg/0.3ml
generic
1
QL
1 / 30 days
AUVI-Q SOLN A-INJ 0.15 MG/0.15ML
epinephrine
BRAND
2
QL
1 / 30 days
auvi-q soln a-inj 0.3 mg/0.3ml
generic
1
QL
1 / 30 days
QL
epinephrine soln a-inj 0.15 mg/0.15ml
generic
1 / 30 days
1
*VASOPRESSORS*
*Anaphylaxis Therapy Agents**
PA
QL
EPINEPHRINE SOLN A-INJ 0.15 MG/0.15ML
epinephrine
BRAND
epinephrine soln a-inj 0.3 mg/0.3ml
generic
1 / 30 days
2
PA
QL
1 / 30 days
1
PA
epipen 2-pak soln a-inj 0.3 mg/0.3ml
generic
1
QL
1 / 30 days
EPIPEN JR 2-PAK SOLN A-INJ 0.15
MG/0.3ML
BRAND
2
QL
1 / 30 days
PAGE 243
PRODUCT DESCRIPTION
BRAND/GEN
TIER
epinephrine
EPIPEN JR SOLN A-INJ 0.15 MG/0.3ML
epinephrine
BRAND
2
QL
1 / 30 days
epipen soln a-inj 0.3 mg/0.3ml
generic
1
QL
1 / 30 days
TWINJECT SOLN A-INJ 0.15 MG/0.15ML
epinephrine
BRAND
2
QL
1 / 30 days
twinject soln a-inj 0.3 mg/0.3ml
generic
1
QL
1 / 30 days
midodrine hcl tab 10 mg
generic
1
midodrine hcl tab 2.5 mg
generic
1
midodrine hcl tab 5 mg
generic
1
DECARA CAP 25000 UNIT
cholecalciferol
BRAND
0
AL
65 to 999 yrs old
decara cap 50000 unit
generic
0
AL
65 to 999 yrs old
ergocalciferol cap 50000 unit
generic
0
AL
65 to 999 yrs old
ergocalciferol powder
generic
0
AL
65 to 999 yrs old
MEPHYTON TAB 5 MG
phytonadione
BRAND
3
phytonadione solution 1 mg/0.5ml
generic
4
PA
vitamin d (ergocalciferol) cap 50000 unit
generic
0
AL
vitamin k1 solution 1 mg/0.5ml
generic
4
PA
vitamin k1 solution 2 mg/ml
generic
4
PA
generic
1
*Vasopressors**
*VITAMINS*
*Oil Soluble Vitamins**
65 to 999 yrs old
*Water Soluble Vitamins**
PAGE 244
Index of covered drugs
Adalimumab
8
8-Mop
Adapalene
129
A
A-Hydrocort
Abacavir Sulfate
8
118
122,123,124
Adapalene-Benzoyl Peroxide
125
Adcetris
71
Adcirca
108
Adefovir Dipivoxil
95
91,94
Adrenaclick
243
Abacavir Sulfate-Lamivudine
92
Adriamycin
74
Abacavir Sulfate-Lamivudine-Zidovudine
91
Advair Diskus
31
Abatacept
11
Advair HFA
31
Abciximab
161
Advate
155
Abelcet
54
Advicor
58
Abilify
90
Afatinib Dimaleate
75
Abilify Discmelt
90
Afinitor
75
Abilify Maintena
90
Afinitor Disperz
75
Abiraterone Acetate
73
Aflibercept
212
AbobotulinumtoxinA
210
Afluria
239
AbobotulinumtoxinA (Glabellar Lines)
134
Afluria Preservative Free
239
Aggrenox
160
239
Abraxane
79
Absorica
122
Agriflu
Acamprosate Calcium
224
Albendazole
22
Albenza
22
Acarbose
Acebutolol HCl
Acetaminophen w/ Codeine
45
101
17
Acetaminophen-Isometheptene-
Albuterol Sulfate
31,32,33
Alcaftadine
216
Alclometasone Dipropionate
130
Dichloralphenazone
172
Aldactazide
137
Acetazolamide
137
Aldesleukin
78
Acetic Acid
153
Alemtuzumab
71
Acetic Acid (Otic)
216
Alendronate Sodium
Acetylcysteine
122
Alferon N
Aciphex
236
Alfuzosin HCl
154
Acitretin
129
Alglucerase
161
Actemra
9
Alglucosidase Alfa
145
139
77
Acthar HP
140
Alimta
69
ActHIB
238
Alinia
24
Active OB
185
Aliskiren Fumarate
65
Aliskiren-Hydrochlorothiazide
65
Alkeran
67
Actoplus met XR
Acyclovir
46
96,97
Acyclovir Sodium
97
Acyclovir Topical
Adacel
PAGE 245
Allopurinol
154
130
Almotriptan Malate
172
233
Alocril
215
Alomide
215
Amphotericin B
54
Alosetron HCl
152
Amphotericin B Cholesteryl Sulfate Complex
54
Amphotericin B Lipid
54
Amphotericin B Liposome
54
Aloxi
Alpha1-Proteinase Inhibitor (Human)
52
228,229
Alphagan P
212
Ampicillin
222
Alphanate/VWF Complex/Human
155
Ampicillin & Sulbactam Sodium
223
AlphaNine SD
155
Ampicillin Sodium
222
Ampyra
226
Alprazolam
Alprolix
Alprostadil
Alprostadil (Vasodilator)
27,28
155,156
100
106,107
Anadrol-50
20
Anagrelide HCl
160,161
Anastrozole
72
20
Alrex
214
Androderm
Alsuma
172
AndroGel
Altabax
127
AndroGel Pump
21
20,21
Altretamine
68
Android
21
Alvimopan
152
Androxy
21
Amantadine HCl
82
Anti-Thymocyte Globulin (Rabbit), Lymphocyte
AmBisome
54
Immune Globulin
99
Ambrisentan
107
Antihemophilic Factor (Human)
156,157,158
Amethyst
111
Antihemophilic Factor (Recombinant)
156,157,158
Amifostine Crystalline
79
Antihemophilic Factor (Recombinant) Plasma/Alblumin
Amikacin Sulfate
6,7
Free
Amiloride & Hydrochlorothiazide
137
Antihemophilic Factor rAHF-PFM
Amiloride HCl
138
Antihemophilic Factor/von Willebrand Factor Complex
Amino Acid Electrolyte w/ Calcium Infusion in
159,160
(Human)
155
155,157,159
D20W
210
Antiinhibitor Coagulant Complex
156
Amino Acid Infusion in D10W
211
Antipyrine-Benzocaine
211
Antithrombin (Human) (Recombinant)
160
211
Antithrombin III (Human)
160
216,217
Aminosalicylic Acid
67
Anzemet
52
Amiodarone HCl
29
Apidra
48
Apidra SoloStar
48
Apixaban
34
Amitiza
Amitriptyline HCl
Amlodipine Besylate
Amlodipine Besylate-Benazepril HCl
Ammonium Lactate
151
44
103
63
Apligraf
135
Apraclonidine HCl
212
111
Apremilast
11
Amoxapine
44
Aprepitant
53,54
Amoxicillin
221,222
Amoxicillin & Pot Clavulanate
Amphetamine-Dextroamphetamine
Amphotec
PAGE 246
223
3
54
Apriso
151
Aptivus
91
Aralast NP
228,229
Aranesp (Albumin Free)
162,163
Arcapta Neohaler
Arestin
31
179
Aripiprazole
90
Armodafinil
6
Armour Thyroid
230
Avonex Pen
226
Avonex Prefilled
227
Axert
172
Axitinib
75
Azacitidine
69
Arranon
69
Azasan
98
Arsenic Trioxide
78
AzaSite
213
Artemether-Lumefantrine
66
Azathioprine
98
Arzerra
71
Azelaic Acid
135
Asacol
151
Azelaic Acid (Acne)
123
Asacol HD
151
Azelastine HCl
209
Asenapine Maleate
88
Azelastine HCl (Ophth)
215
Asmanex 120 Metered Doses
30
Azelex
123
30
Azilect
84
30
Azilsartan Medoxomil
62
30
Azithromycin
168
30
Azithromycin (Ophth)
213
Asparaginase
77
Azithromycin Hydrogencitrate
168
Asparaginase Erwinia Chrysanthemi
77
Aztreonam
22
Aztreonam Lysine
22
Aspirin-Dipyridamole
160
Astagraf XL
98
Atabex EC
185
Atazanavir Sulfate
Atenolol
Atenolol & Chlorthalidone
Atomoxetine HCl
93
101
63
5
B
B-Complex w/ C & Folic Acid
180,181
B-Complex w/ C-Biotin-D & Folic Acid
180
B-Complex w/ C-Biotin-D-Zinc & Folic Acid
181
B-Complex w/ C-Biotin-E-Minerals & Folic Acid
180
Atorvastatin Calcium
58
B-Complex w/ C-Biotin-Minerals & Folic Acid
180
Atovaquone
24
B-Complex w/ C-Zn & Folic Acid
180
Atovaquone-Proguanil HCl
66
B-Complex w/ Lysine-Min-Fe & Folic Acid
180
Atripla
91
B-Complex w/ Lysine-Zn & Folic Acid
181
Atropine Sulfate
235
B-Nexa
185
Atropine Sulfate (Ophthalmic)
212
Bacitracin-Poly-Neomycin-HC
214
Bacitracin-Polymyxin-Neomycin HC
127
Atrovent HFA
29
Atryn
160
Baclofen
208
Aubagio
226
Bactroban Nasal
209
Auvi-Q
243
Bal-Care DHA
186
Avandia
48
Bal-Care DHA Essential
186
Avastin
71
Balsalazide Disodium
151
Avelox
149
Baraclude
95
Avodart
154
BCG Live Intravesical
78
Avonex
226
Bebulin
PAGE 247
156
Bebulin VH
156
BiDil
Becaplermin
136
Biltricide
106
22
Beclomethasone Dipropionate
31
Bimatoprost
Benazepril & Hydrochlorothiazide
63
Bisacodyl-PEG 3350-Pot Chloride-Sod Bicarb-Sod
Benazepril HCl
60
Chloride
Bendamustine HCl
69
Bisoprolol & Hydrochlorothiazide
BeneFIX
156
Benicar
216
167
63
Bisoprolol Fumarate
101
61
Bivigam
217
Benicar HCT
63
Blephamide
214
Benzonatate
121
Blood Glucose Calibration
171
Blood Glucose Monitoring Supplies
171
Benzoyl Peroxide
122,123,124,125,126
Benzoyl Peroxide w/ Cleanser
123
Boceprevir
Benzoyl Peroxide-Erythromycin
124
Boostrix
Benztropine Mesylate
82
96
233
Bortezomib
77
Benzyl Alcohol (Pediculicide)
135
Bosentan
Bepotastine Besilate
215
Bosulif
75
Bepreve
215
Bosutinib
75
Berinert
160
Botox
210
Besifloxacin HCl
213
Botox Cosmetic
134
Besivance
213
BP FoliNatal Plus B
186
Betamethasone Dipropionate (Topical)
130
BP MultiNatal Plus
186
Betamethasone Dipropionate Augmented
130
Bravelle
140
Betamethasone Sod Phosphate & Acetate
118
Brentuximab Vedotin
71
130,131,133
Brimonidine Tartrate
212
Betamethasone Valerate
107,108
Betaseron
227
Brimonidine Tartrate-Timolol Maleate
211
Betaxolol HCl
101
Bromday
215
Betaxolol HCl (Ophth)
211
Bromfenac Sodium (Ophth)
215
Bethanechol Chloride
238
Bromocriptine Mesylate
82
Bromocriptine Mesylate (Diabetes)
47
Bethkis
7
Betimol
211
Budesonide
Betoptic-S
211
Budesonide (Inhalation)
118,121
30,31
Bevacizumab
71
Budesonide (Nasal)
Bexarotene
78
Budesonide-Formoterol Fumarate Dihydrate
Bexarotene (Topical)
129
Bexxar
71
Beyaz
112
Bicalutamide
72
210
32,33
Bumetanide
138
Buphenyl
145
Buprenorphine
19,20
Buprenorphine HCl
19
Bicillin C-R
223
Buprenorphine HCl-Naloxone HCl Dihydrate
19,20
Bicillin C-R 900/300
223
Bupropion HCl
40,41
Bicillin L-A
222
Bupropion HCl (Smoking Deterrent)
BiCNU
PAGE 248
67
Buspirone HCl
228
27
Busulfan
68
Capsaicin & Cleansing Gel
Butalbital-Acetaminophen
11
Captopril
Butalbital-Acetaminophen-Caffeine
Butalbital-Acetaminophen-Caffeine w/ Codeine
11,12
18
135
60
Captopril & Hydrochlorothiazide
Carbamazepine
63,64
36,37,38
Butalbital-Aspirin-Caffeine
11,12
Carbamazepine (Antipsychotic)
84
Butalbital-Aspirin-Caffeine w/Cod
17,18
Carbidopa
82
Butenafine HCl
128
Carbidopa-Levodopa
Butoconazole Nitrate (One Dose)
242
Carbidopa-Levodopa-Entacapone
83
Carbinoxamine Maleate
55
Carboplatin
67
Butorphanol Tartrate
Butrans
19
19,20
82,83
Bydureon
48
Cardene SR
103
Byetta 10 MCG Pen
48
Carfilzomib
76
Byetta 5 MCG Pen
48
Carimune NF
217
101
Carisoprodol
208,209
Bystolic
C
Carmustine
67
Carmustine in Polifeprosan
68
C-Nate DHA
186
Carteolol HCl (Ophth)
C1 Esterase Inhibitor (Human)
160
Carvedilol
211
100,101
Cabazitaxel
81
Cabergoline
146
Cavan One Omega
186
Cafergot
172
Cavan Prenatal/EC Calcium
186
Calcipotriene
129
Cavan-Alpha
186
Cavan-EC SOD DHA
186
Calcipotriene-Betamethasone Dipropionate
131,133
Caspofungin Acetate
54
Calcitonin (Salmon)
139
Cavan-Folate DHA
186
Calcitriol
145
Cavan-Heme Omega
186
Calcitriol (Topical)
129
Cayston
22
Calcium Acetate (Phosphate Binder)
152
Cefaclor
109
Calcium Chloride (Dihydrate)
174
Cefaclor ER
109
Calcium Gluconate
174
Cefaclor Monohydrate
109
Calcium PNV
186
Cefadroxil
108
Campath
71
Cefazolin in D5W
108
Campral
224
Cefazolin Sodium
108
Campral Dose Pak
224
CeFAZolin Sodium
108
Camptosar
81
Cefazolin Sodium and Dextrose
108
Canagliflozin
51
CeFAZolin Sodium-Dextrose
108
Canakinumab
9
Cefdinir
110
Canasa
Cancidas
Candesartan Cilexetil
151
54
61,62
Cefepime HCl
110,111
Cefepime HCl and Dextrose
111
Cefepime-Dextrose
111
Candesartan Cilexetil-Hydrochlorothiazide
63
Cefixime
110
Capecitabine
69
Cefotaxime Sodium
110
PAGE 249
Cefoxitin Sodium
109
Cholestyramine Light
57
Cefpodoxime Proxetil
110
Choline Fenofibrate
58
Cefprozil
109
Choriogonadotropin Alfa
141
Ceftibuten
110
Chorionic Gonadotropin
140,141
Ceftin
109
Cialis
Cefuroxime Axetil
109
Ciclopirox
Cefuroxime Sodium
109,110
106
127,128
Ciclopirox Olamine
127
Cefuroxime Sodium and Dextrose
109
Cidofovir
95
Cefuroxime Sodium-Dextrose
109
Cilostazol
161
Cefuroxime-Dextrose
109
Cimetidine
235
CeleBREX
9
Cimzia
151
Celecoxib
9
Cimzia Prefilled
151
CellCept
98
Cimzia Starter Kit
151
Cenestin
147
Cinryze
160
108,109
Cipro HC
217
Ceprotin
160
Ciprodex
217
Ceredase
161
Ciprofloxacin
150
Cerezyme
161
Ciprofloxacin HCl
Cephalexin
Ceritinib
77
149,150
Ciprofloxacin HCl (Ophth)
213
Certolizumab Pegol
151
Ciprofloxacin HCl (Otic)
216
Cervical Caps
170
Ciprofloxacin in D5W
150
Cesamet
53
Ciprofloxacin-Ciprofloxacin HCl
150
Cetraxal
216
Ciprofloxacin-Dexamethasone
217
Cetrorelix Acetate
141
Ciprofloxacin-Hydrocortisone
217
Cetrotide
141
Cisplatin
67
Citalopram Hydrobromide
41
Cetuximab
71
Cevimeline HCl
179
CitraNatal 90 DHA
187
Chantix
228
CitraNatal Assure
187
Chantix Continuing Month Pak
228
CitraNatal B-Calm
187
Chantix Starting Month Pak
228
CitraNatal DHA
187
CitraNatal Harmony
187
CitraNatal Rx
187
Chemet
Chlorhexidine Gluconate (Mouth-Throat)
Chloroquine Phosphate
Chlorothiazide
52
179
66
Cladribine
69
138,139
Claforan
110
Chlorpromazine HCl
89
Claravis
124
Chlorpropamide
51
Clarinex
56
Chlorthalidone
138,139
Chlorzoxazone
208
Clemastine Fumarate
Choice-OB+DHA
187
Climara Pro
146
Cholecalciferol
244
Clindagel
124
Cholestyramine
57
PAGE 250
Clarithromycin
Clindamycin HCl
168,169
55
25
Clindamycin Palmitate Hydrochloride
25
Colistimethate Sodium
Clindamycin Phosphate
25
Collagenase
Clindamycin Phosphate (Topical)
124
Clindamycin Phosphate in D5W
25
Clindamycin Phosphate Vaginal
Clindamycin Phosphate-Benzoyl Peroxide
22
134
Collagenase Clostridium Histolyticum
98
Coly-Mycin S
217
242
Colyte with Flavor Packs
166
124
Combigan
211
Clindamycin Phosphate-Benzoyl Peroxide
Combivent Respimat
32
(Refrigerate)
124
Combivir
91
Clinimix E/Dextrose (5/20)
210
Complera
91
Clinimix/Dextrose (2.75/5)
211
Complete Natal DHA
187
211
Complete-RF Prenatal
187
211
CompleteNate
187
211
Comvax
239
Clinimix/Dextrose (5/25)
211
Concept DHA
187
Clobetasol Propionate
131
Concept OB
188
Clocortolone Pivalate
131
Conjugated Estrogens-Medroxyprogesterone
Cloderm
131
Acetate
147
Clofarabine
69
Copaxone
227
Clolar
69
Copper (IUD)
117
CoreNate-DHA
188
Clomiphene Citrate
140,141
Clomipramine HCl
44
Corifact
156
Clonazepam
36
Corticotropin
140
Clonidine HCl
62
Cortisporin
127
Cortisporin-TC
217
Clonidine HCl (ADHD)
4
Clopidogrel Bisulfate
161
Cosmegen
74
Clotrimazole (Topical)
127
Cosopt PF
211
Clotrimazole w/ Betamethasone
127
Cosyntropin
136
Clozapine
Coagulation Factor IX
87
155,158
Coumadin
33
Creon
136
Coagulation Factor IX (Recomb) Fc Fusion Protein
Crestor
58
(rFIXFc)
155,156
Crinone
242
Coagulation Factor IX (Recombinant)
156,159
Crixivan
91
29
Coagulation Factor VIIa (Recombinant)
158
Cromolyn Sodium
Coagulation Factor XIII A-Subunit (Recombinant)
159
Cromolyn Sodium (Ophth)
215
Coartem
66
Cross-Linked Hyaluronate
209
Codeine Sulfate
12
Crotamiton
135
Colchicine
154
Cubicin
24
Colchicine w/ Probenecid
154
Cultured Skin Substitute
Colcrys
154
Cuprimine
135
97
Colesevelam HCl
57
Cuvposa
234
Colestipol HCl
57
Cyanocobalamin
161
PAGE 251
Cyclobenzaprine HCl
Cyclophosphamide
208
67,68
Delavirdine Mesylate
93
Delestrogen
147
Cycloserine
66
Delflex-LC/2.5% Dextrose
CycloSERINE
66
Delzicol
151
Cycloset
47
Demeclocycline HCl
229
Denavir
130
Cyclosporine
Cyclosporine (Ophth)
Cyclosporine Modified (For Microemulsion)
98,99
213
98,99
99
Denileukin Diftitox
78
Denosumab
140
Cyproheptadine HCl
56
Depen Titratabs
97
Cyramza
71
Depo-Estradiol
148
Depo-Medrol
118
117
Cysteamine Bitartrate
153
Cytarabine
69
Depo-SubQ Provera 104
Cytarabine Liposome
70
DepoCyt
70
Cytogam
218
Derma-Smoothe/FS Body
131
Cytomegalovirus Immune Globulin (Human)
218
Derma-Smoothe/FS Scalp
131
D
Desipramine HCl
44
Desloratadine
56
Dabigatran Etexilate Mesylate
36
Desmopressin Acetate
146
Dabrafenib Mesylate
77
Desmopressin Acetate Refrigerated
145
Desmopressin Acetate Spray
146
Desmopressin Acetate Spray Refrigerated
146
Dacarbazine
77,78
Dactinomycin
74
Dalfampridine
226
Desogestrel & Ethinyl Estradiol
Dalteparin Sodium
35
Desogestrel-Ethinyl Estradiol
Danazol
21
(Biphasic)
Dapsone
24,25
Daptacel
233
111,112,116
112,113,115,116
Desogestrel-Ethinyl Estradiol (Triphasic)
112,116
Desonide
131,133
131,133
Daptomycin
24
Desoximetasone
Daraprim
66
Desvenlafaxine
43
43
Darbepoetin Alfa-Polysorbate 80
162,163
Desvenlafaxine Succinate
Darifenacin Hydrobromide
237,238
Dexamethasone
118,119,121
Darunavir Ethanolate
93
Dexamethasone (Ophth)
214,215
Dasatinib
76
Dexamethasone Intensol
118
Daunorubicin Citrate Liposome
74
Dexamethasone Sodium Phosphate
Daunorubicin HCl
74
Dexamethasone Sodium Phosphate (Ophth)
214
DaunoXome
74
Dexilant
236
236
Decara
244
Dexlansoprazole
Decavac
233
Dexmethylphenidate HCl
118,119
5
Decitabine
69
DexPak 13 Day
119
Deferasirox
52
DexPak 6 Day
119
Deferiprone
52
Dexrazoxane
79
Deferoxamine Mesylate
52
Dextranomer-Sodium Hyaluronate
98
PAGE 252
Dextroamphetamine Sulfate
3,4
Dimethyl Fumarate
227
Dextromethorphan HBr-Quinidine Sulfate
227
Dipentum
151
Dextrose in Lactated Ringers
174
Diph, Acellular Pertussis, Tetanus Tox & Haemophilus
Dextrose in Ringers
174
B Poly
Dextrose w/ Sodium Chloride
174
Diph-Ac Pert-Tet Tox Ad-Polio IPV-Haemophil B Poly
Dextrose-NaCl
174
Vac
Dialyvite 3000
180
Diph-Tetanus Tox Ad-Acell Pertussis & Polio Virus,
Dialyvite 5000
180
IPV Vac
Dialyvite Supreme D
182
Diph-Tetanus Tox-Acell Pert-Hepatitis B Recomb-Polio
Dialyvite/Zinc
180
IPV Vac
Dianeal Low Calcium/1.5% Dex
99
234
234
234
234
Diphenhydramine HCl
55
Dianeal PD-2/1.5% Dextrose
100
Diphenhydramine-Hydrocortisone-Nystatin-
100
Tetracycline
100
Diphenhydramine-Lidocaine-Alum Hydroxide-Mg
Diaphragm Arc-Spring
170
Hydroxide-Simeth
Diaphragm Wide Seal
170,171
Diaphragms
170
179
178
Diphenoxylate w/ Atropine
51
Diphtheria, Acellular Pertussis & Tetanus
Diazepam
28
Toxoids
233,234
Diazepam (Anticonvulsant)
36
Diphtheria-Tetanus Toxoids
233
Diazoxide
47
Diphtheria-Tetanus Toxoids (DT)
233
Dibenzyline
61
Diphtheria-Tetanus Toxoids DT
233
161
Diclofenac Potassium
9
Dipyridamole
Diclofenac Sodium
9
Disopyramide Phosphate
28
Diclofenac Sodium (Ophth)
215
Disulfiram
224
Diclofenac Sodium (Topical)
127
Diuril
139
Diclofenac w/ Misoprostol
Dicyclomine HCl
Didanosine
Difenoxin w/ Atropine
9
234
91,94
Divalproex Sodium
40
Divigel
148
Docefrez
79
52
Docetaxel
Differin
124
DOCEtaxel
Dificid
170
Docosavit
188
Diflorasone Diacetate
132
Dofetilide
29
12
Dolasetron Mesylate
52
Difluprednate
214
Dolutegravir Sodium
94
Digoxin
106
Donepezil Hydrochloride
Dihydroergotamine Mesylate
172
Doribax
24
24
Diflunisal
79,80,81
80
224,225
Dilantin
39
Doripenem
Dilantin Infatabs
39
Dornase Alfa
229
Diltiazem HCl
103,104
Dorzolamide HCl
215
Diltiazem HCl Coated Beads
103,104
Dorzolamide HCl-Timolol Maleate
211
Diltiazem HCl Extended Release Beads
PAGE 253
103
Doxazosin Mesylate
62
Doxepin HCl
45
Edge OB
189
Doxepin HCl (Antipruritic)
129
Edurant
91
Doxercalciferol
145
Efavirenz
94
Doxil
74
Efavirenz-Emtricitabine-Tenofovir Disoproxil
Doxorubicin HCl
74
Fumarate
Doxorubicin HCl Liposomal
74
Effient
161
Doxycycline (Monohydrate)
229
Egrifta
141,142
Doxycycline Calcium
230
Electrolyte-56 in Dextrose
175
Doxycycline Hyclate
229,230
Electrolyte-B in Dextrose
174
Dronabinol
53
Electrolyte-H in Dextrose
174
Dronedarone HCl
29
Electrolyte-MB in Dextrose
174
Electrolyte-P in Dextrose
174
Electrolyte-R in Dextrose
175
Electrolyte-S
174
Drospirenone-Ethinyl Estradiol
112,113,114,115,116
Drospirenone-Ethinyl Estradiol-Levomefolate
Calcium
112,116
91
Droxia
161
Elelyso
161
Duet DHA
189
Elestrin
148
Duet DHA 400
188
Eletriptan Hydrobromide
172
Duet DHA 400EC
188
Elidel
134
Duet DHA 430
188
Eligard
72
Duet DHA 430EC
188
Eliquis
34
Duet DHA Balanced
188
Elite OB with DHA
189
Duet DHA Complete
188
Elite-OB
189
Duet DHA EC
188,189
Elite-OB 400
189
DuLeek-Dp
161,162
Ella
117
Dulera
32
Elmiron
154
Duloxetine HCl
43
Elosulfase Alfa
145
Durezol
214
Eloxatin
68
Dutasteride
154
Elspar
77
Dutoprol
64
Eltrombopag Olamine
164
DynaCirc CR
104
Elvitegravir-Cobicistat-Emtricitabine-Tenofovir
Dyrenium
138
Emadine
Dysport
210
Emcyt
Dysport (Glabellar Lines)
134
Emedastine Difumarate
E
94
215
72
215
Emend
53,54
Emsam
41
91
E.E.S. 400
169
Emtricitabine
Ecallantide
160
Emtricitabine-Rilpivirine-Tenofovir Disoproxil
Econazole Nitrate
127
Fumarate
91
Eculizumab
160
Emtricitabine-Tenofovir Disoproxil Fumarate
94
Edarbi
62
Emtriva
91
Edecrin
138
Enablex
237,238
PAGE 254
Enalapril Maleate
60
Erythrocin Stearate
169
Enalapril Maleate & Hydrochlorothiazide
64
Erythromycin
125
Enbrel
11
Erythromycin (Acne Aid)
125
Enbrel SureClick
11
Erythromycin (Ophth)
213
Erythromycin Base
169
Endometrin
242
Enfuvirtide
92
Erythromycin Base (Coated)
170
Engerix-B
239
Erythromycin Ethylsuccinate
169
Enjuvia
148
Erythromycin Lactobionate
169
Erythromycin Stearate
169
Enoxaparin Sodium
34,35
Entacapone
82
Erythromycin-Sulfisoxazole
Entecavir
95
Escavite
182
Escavite D
182
Entereg
Enzalutamide
152
73
Escitalopram Oxalate
24
41
Epiduo
125
Esomeprazole Magnesium
Epinastine HCl (Ophth)
215
Esterified Estrogens
149
Esterified Estrogens & Methyltestosterone
147
243
Estrace
242
32
Estradiol
Epinephrine
EPINEPHrine
Epinephrine HCl
243,244
236,237
148,149
EpiPen Jr
244
Estradiol Acetate Vaginal
242
EpiPen Jr 2-Pak
243
Estradiol Cypionate
148
Estradiol Vaginal
242
Estradiol Valerate
147
Epirubicin HCl
Epivir
74
91,92
Epivir HBV
91
Estradiol Valerate-Dienogest
114
Eplerenone
65
Estradiol-Levonorgestrel
146
Epoetin Alfa
163,164
Estramustine Phosphate Sodium
72
Epogen
163
Estrasorb
148
Epoprostenol Sodium
107
Estring
242
Eprosartan Mesylate
62
Estrogel
148
Epzicom
92
Estrogens, Conjugated
149
Equetro
84
Estrogens, Conjugated Synthetic A
147
Erbitux
71
Estrogens, Conjugated Synthetic B
148
Ergocalciferol
244
Estrogens, Conjugated Vaginal
242
Ergoloid Mesylates
228
Estropipate
148
Ergotamine w/ Caffeine
172
Eszopiclone
166
Eribulin Mesylate
80
Etanercept
11
Erlotinib HCl
77
Ethacrynic Acid
138
127
Ethambutol HCl
66
Ethosuximide
40
Ertaczo
Erwinaze
77
Ery-Tab
169
Ethynodiol Diacet & Eth Estrad
EryPed 400
169
Etodolac
9,10
Erythrocin Lactobionate
169
Etonogestrel
117
PAGE 255
113,116
Etonogestrel-Ethinyl Estradiol
Etopophos
Etoposide
117
80
80,81
Femring
242
Fenofibrate
57
Fenofibrate Micronized
57
Etoposide Phosphate
80
Fenofibric Acid
58
Etravirine
92
Fenoprofen Calcium
10
Euflexxa
209
Fentanyl
Eurax
135
Fentanyl Citrate
Evamist
149
Feraheme
164
165
12,13
12
Everolimus
75
Ferric Carboxymaltose
Everolimus (Immunosuppressant)
99
Ferriprox
Exalgo
12
Ferrous Sulfate
165
52
Exelderm
127
Ferumoxytol
164
Exelon
225
Fesoterodine Fumarate
238
Exemestane
72
Fexmid
208
Exenatide
48
Fibrinogen Concentrate (Human)
159
Exjade
52
Fidaxomicin
170
Extavia
227
Filgrastim
Extra-Virt Plus DHA
189
Finacea
135
Extraneal
100
Finasteride
154
Eylea
212
Fingolimod HCl
227
First-Hydrocortisone
132
First-Lansoprazole
236
First-Marys Mouthwash
179
First-Mouthwash BLM
178
First-Omeprazole
236
156,158
First-Progesterone VGS 100
243
Factor XIII Concentrate (Human)
156
243
FaLessa
112
243
Famciclovir
97
243
Famotidine
235
243
Ezetimibe
Ezetimibe-Simvastatin
59
56,57
F
Factive
Factor IX Complex
150
163,164
Fanapt
85
First-Vancomycin 25
22
Fanapt Titration Pack
85
First-Vancomycin 50
22
Faslodex
72
Flagyl ER
22
FazaClo
87
Flarex
214
Febuxostat
154
Flavoxate HCl
238
Feiba NF
156
Flebogamma DIF
218
Feiba VH Immuno
156
Flecainide Acetate
29
Flovent Diskus
30
Felbamate
39
Felodipine
104
Flovent HFA
FemCap
170
Floxuridine
Femecal OB
189
Fluarix
PAGE 256
30,31
70
239
Fluarix Quadrivalent
239
Fluzone
240
Flublok
240
Fluzone High-Dose
240
Flucelvax
240
Fluzone Pediatric PF
240
Fluzone Preservative Free
240
Fluzone Quadrivalent
240
Fluconazole
Fluconazole in Dextrose
55
54,55
Fluconazole in NaCl
55
FML
214
Fludarabine Phosphate
70
FML Forte
214
Fludrocortisone Acetate
121
Focalgin-B
189
Flulaval
240
Folbecal
189
Flulaval Quadrivalent
240
Folcal DHA
189
FluMist
240
Folcaps Care One
189
FluMist Quadrivalent
240
Folcaps Omega 3
189
Flunisolide
210
Folgard OS
181
Flunisolide (Nasal)
210
Folic Acid
Fluocinolone Acetonide
131,132
161,162
Folivane-OB
190
Fluocinolone Acetonide (Ophth)
215
Folivane-PRx DHA NF
190
Fluocinolone Acetonide (Otic)
217
Follistim AQ
140
Fluocinonide
132
Follitropin Alfa
Fluor-a-day
176
Follitropin Beta
Fluorabon
176
Folotyn
70
Fluorometholone (Ophth)
214
Foradil Aerolizer
32
Fluorometholone Acetate
214
Formoterol Fumarate
32
Fluorouracil
Fluorouracil (Topical)
Fluoxetine HCl
140,141
140
70
Forteo
139
128
Fortical
139
41,42
Fosamprenavir Calcium
92
Fluoxymesterone
21
Fosaprepitant Dimeglumine
54
Fluphenazine Decanoate
89
Fosfomycin Tromethamine
237
Fluphenazine HCl
89
Fosinopril Sodium
60
Fosinopril Sodium & Hydrochlorothiazide
64
Flura-Drops
176
Flurbiprofen
10
Fosrenol
152
216
Fragmin
35
Flurbiprofen Sodium
Flutamide
Fluticasone Propionate
Fluticasone Propionate HFA
Fluticasone Propionate (Inhalation)
Fluticasone Propionate (Nasal)
72
132
30,31
30
Frova
172
Frovatriptan Succinate
172
Fulvestrant
72
Furosemide
138
210
Fusilev
79
Fluticasone-Salmeterol
31
Fuzeon
92
Fluvastatin Sodium
58
Fluvirin
240
G
Fluvirin Preservative Free
240
Gabapentin
Fluvoxamine Maleate
PAGE 257
42
Gabapentin (PHN)
37
227
Gabapentin Enacarbil
Glucagon (rDNA)
47
39
Glucagon Emergency
47
Galantamine Hydrobromide
225
Glucagon HCl (rDNA)
47
GamaSTAN S/D
218
Glucarpidase
79
Gabitril
Gammagard
228
218,219
Glucose Blood
136
182
Gammagard S/D
218
Glutofac-ZX
Gammagard S/D Less IgA
218
Glyburide
51
Gammaked
219
Glyburide-Metformin
46
Gammaplex
219
Glycate
234
Gamunex
219
Glycerol Phenylbutyrate
145
Glycine (GU Irrigant)
153
95
Glycine Diluent
224
Ganirelix Acetate
141
Glycopyrrolate
234
Gardasil
241
Glyset
Gatifloxacin (Ophth)
213
Golimumab
Gattex
153
Golytely
Gefitinib
76
Gonal-f
Gel-One
209
Gamunex-C
Ganciclovir Sodium
219,220
45
8
167
140,141
Gonal-f RFF
141
Gemcitabine HCl
70
Gonal-f RFF Pen
141
Gemfibrozil
58
Goserelin Acetate
73
Gemifloxacin Mesylate
150
Gralise
227
Generess FE
113
Granisetron HCl
Genotropin
142
Granix
Genotropin MiniQuick
142
Grifulvin V
54
52
163
Gentamicin in Saline
7
Griseofulvin Microsize
54
Gentamicin Sulfate
7
Griseofulvin Ultramicrosize
54
Gentamicin Sulfate (Ophth)
213
Guaifenesin-Codeine
Gentamicin Sulfate (Topical)
127
Guanfacine HCl
Geodon
84
Gesticare
190
Gesticare DHA
190
Gilenya
227
Gilotrif
75
Glatiramer Acetate
227
121,122
62
Guanfacine HCl (ADHD)
4
Gynazole-1
242
H
Haemophilus B Polysac Conj Vac
238,239
Haemophilus B Polysac Conj-Hepatitis B (Recomb)
Gleevec
75
Vaccines
239
Gliadel Wafer
68
Halaven
80
Glimepiride
51
HalfLytely with Flavor Packs
167
Glipizide
51
Halobetasol Propionate
132
Glipizide-Metformin HCl
46
Haloperidol
87
GlucaGen
47
Haloperidol Decanoate
87
GlucaGen HypoKit
47
Haloperidol Lactate
87
PAGE 258
Havrix
241
HumuLIN 70/30
49
Helixate FS
156
HumuLIN 70/30 KwikPen
49
HemeNatal OB
190
HumuLIN N
49
HemeNatal OB + DHA
190
HumuLIN N KwikPen
49
HumuLIN R
49
HumuLIN R U-500 (CONCENTRATED)
49
Hemofil M
156,157
HepaGam B
220
Heparin (Porcine) in NaCl
35
Hyalgan
209
Heparin (Porcine) in Sodium Chloride
35
Hyaluronan
209
Heparin Sodium (Porcine)
36
Hycamtin
81
Hydralazine HCl
65
Hepatitis A (Inactivated)-Hepatitis B (Recombinant)
Vaccines
241
Hydrochlorothiazide
Hepatitis A Vaccine
241
Hydrocodone Polistirex-Chlorpheniramine
Hepatitis B Immune Globulin (Human)
220
Polistirex
121
239,241
Hydrocodone w/ Homatropine
121
Herceptin
71
Hydrocodone-Acetaminophen
18,19
Hexachlorophene
90
Hydrocodone-Ibuprofen
Hexalen
68
Hydrocortisone
Hiberix
238
Hepatitis B Vaccine (Recomb)
139
19
119
Hydrocortisone (Intrarectal)
21
73
Hydrocortisone (Rectal)
22
Histrelin Acetate (CPP)
145
Hydrocortisone (Topical)
Hizentra
220
Hydrocortisone Acetate (Rectal)
Hizentra 20%
220
Hydrocortisone Acetate (Topical)
Horizant
228
Hydrocortisone Acetate w/ Pramoxine
HP Acthar
140
Hydrocortisone Butyrate
132
HumaLOG
49
Hydrocortisone Butyrate Hydrophilic Lipo Base
132
HumaLOG KwikPen
48
Hydrocortisone Sod Succinate
HumaLOG Mix 50/50
48
Hydrocortisone Valerate
133
HumaLOG Mix 50/50 KwikPen
48
Hydrocortisone w/Acetic Acid
217
HumaLOG Mix 50/50 Pen
48
Hydromorphone HCl
HumaLOG Mix 75/25
49
HYDROmorphone HCl ER
13
HumaLOG Mix 75/25 KwikPen
49
Hydroxychloroquine Sulfate
66
HumaLOG Mix 75/25 Pen
49
Hydroxyprogesterone Caproate
HumaLOG Pen
49
Hydroxyurea
Histrelin Acetate
Human Papillomavirus (HPV) Quadrivalent
130,132,133
21,22
132
21
118,121
12,13
224
78
Hydroxyurea (Sickle Cell Anemia)
161
Recombinant Vaccine
241
Hydroxyzine HCl
27
Humate-P
157
Hydroxyzine Pamoate
27
Humatrope
142,143
Hylan
209
Humira
8
Hyoscyamine Sulfate
Humira Pen
8
HyperHEP B S/D
220
Humira Pen-Crohns Starter
8
HyperRAB S/D
220
Humira Pen-Psoriasis Starter
8
HyperRHO S/D
220
PAGE 259
234,235
HyperSal
122
Infliximab
152
HyperTET S/D
220
Influenza Virus Vaccine Live
240
Influenza Virus Vaccine Live Quadrivalent
240
I
Influenza Virus Vaccine Recombinant Hemagglutinin
Ibandronate Sodium
139
(HA)
240
Ibrutinib
75
Influenza Virus Vaccine Split
Ibuprofen
10
Influenza Virus Vaccine Split High-Dose Preservative
Iclusig
75
Free
Idarubicin HCl
74
Influenza Virus Vaccine Split Preservative Free239,240
Ifex
68
Influenza Virus Vaccine Split Quadrivalent 239,240,241
Ifosfamide
68
Influenza Virus Vaccine Tissue-Cultured Subunit
Ilaris
9
Ilevro
216
239,240
240
240
Influenza Virus Vaccine Types A & B Preservative
Free
239,240,241
Iloperidone
85
Influenza Virus Vaccine Types A & B Surface
Imatinib Mesylate
75
Antigen
240,241
Imbruvica
75
Ingenol Mebutate
128,129
Imiglucerase
161
Injectafer
165
Imipramine HCl
45
Inlyta
75
Imipramine Pamoate
45
Innohep
36
Imiquimod
134
InnoPran XL
Immune Globulin (Human)
218
Insulin Aspart
50
Insulin Aspart Protamine & Aspart (Human)
50
Insulin Detemir
49
218,219,220
Insulin Glargine
49
220,221
Insulin Glulisine
48
Immune Globulin (Human) IV
217,218,219,220,221
Immune Globulin (Human) IV or
Subcutaneous
Immune Globulin (Human) Subcutaneous
101,102
Imogam Rabies-HT
220
Insulin Isophane & Reg (Human)
49,50
Implanon
117
Insulin Isophane (Human)
49,50
iNatal Advance
190
Insulin Lispro (Human)
48,49
Inatal GT
190
Insulin Lispro Protamine & Lispro (Human)
48,49
iNatal Ultra
190
Insulin Regular (Human)
49,50
Incivek
95
Increlex
144
Indacaterol Maleate
Indapamide
31
Intelence
92
Interferon Alfa-n3
77
Interferon alfacon-1
95
139
Interferon Beta-1a
226,227
Indinavir Sulfate
91
Interferon Beta-1b
227
Indocin
10
Intuniv
4
Indomethacin
10
Invega
86
Infanate Balance
190
Invega Sustenna
Infanate DHA
190
Invirase
92
Infanrix
233
Invokana
51
Infergen
95
PAGE 260
Ionosol-B in D5W
85,86
174
Ionosol-MB in D5W
174
Janumet XR
46
Iopidine
212
Januvia
47
Ipol
241
Jentadueto
46
29
Jevtana
81
209
Juxtapid
59
Ipratropium Bromide
Ipratropium Bromide (Nasal)
Ipratropium Bromide HFA
29
Ipratropium-Albuterol
32
K
Irbesartan
62
K-Tab
177
Irbesartan-Hydrochlorothiazide
64
Kalbitor
160
Iressa
76
Kaletra
92
Irinotecan HCl
81,82
Iron & B-12 w/ Vitamins
181
Iron Dextran
164,165
Kalydeco
229
Kanamycin Sulfate
7
KCl in D5W Lactated Ringers
174
Iron Polysaccharide Complex-Vit B12-Folic Acid
164
KCl in Dextrose-NaCl
175
Iron Sucrose
165
KCl-Lactated Ringers-D5W
175
Iron w/ Vitamins
181
Kenalog
119
Isentress
92
Kepivance
78
Isocarboxazid
41
Ketek
24
55
Isolyte-H in D5W
174
Ketoconazole
Isolyte-P in D5W
174
Ketoconazole (Topical)
Isolyte-S
174
Ketoprofen
10
Isometheptene-Caffeine-Acetaminophen
172
Ketorolac Tromethamine
10
Isometheptene-Caffeine-APAP
172
Ketorolac Tromethamine (Bulk)
111
127,128
Isoniazid
67
Ketorolac Tromethamine (Ophth)
216
Isoniazid & Rifampin
66
Kinrix
234
Isosorbide Dinitrate
26
Klor-Con
177
Klor-Con M15
177
Koate-DVI
157
Isosorbide Dinitrate-Hydralazine HCl
Isosorbide Mononitrate
Isotretinoin
Isradipine
Istalol
106
26
122,123,124,125,126
104,105
211
Kogenate FS
157,158
Kogenate FS Bio-Set
157
Kolnatal DHA
190
Istodax
76
Korlym
Itraconazole
55
Krystexxa
154
Kuvan
145
Ivacaftor
229
47
Ivermectin
22
Kynamro
57
Ixabepilone
80
Kyprolis
76
Ixempra Kit
80
J
L
L-Methylfolate PNV DHA
190
101
Jakafi
76
Labetalol HCl
Janumet
46
Lacosamide
PAGE 261
38,39
Lactated Ringer's
Lactated Ringer's (Irrigation)
175
Levoleucovorin Calcium
79
99
Levomefolate DHA
191
Lactulose
167
Levomefolate PNV
191
Lactulose (Encephalopathy)
152
Levonorgestrel & Eth
Lamivudine
91,92
Estradiol
Lamivudine-Zidovudine
91,92
Levonorgestrel (Emergency OC)
117
Levonorgestrel (IUD)
117
Lamotrigine
37
111,112,113,114,115,116
Lancets
171
Levonorgestrel-Eth Estradiol
Lansoprazole
236
(Triphasic)
Lanthanum Carbonate
152
Levonorgestrel-Ethinyl Estradiol & Folic Acid
112,113,114,116
Lantus
49
Levonorgestrel-Ethinyl Estradiol (91-
Lantus for OptiClik
49
Day)
Lantus SoloStar
49
Levonorgestrel-Ethinyl Estradiol (Continuous)
Lapatinib Ditosylate
77
Levorphanol Tartrate
112
111,112,113,115
111
13
Lastacaft
216
Levothyroxine Sodium
Latanoprost
216
Lexiva
92
84,85
Lialda
151
135
Latuda
Leflunomide
11
Lidocaine
Lenalidomide
98
Lidocaine HCl
Lescol XL
58
Lidocaine HCl (Cardiac)
Letairis
230,231,232,233
134,135
28,168
107
Lidocaine HCl (Local Anesth.)
168
Letrozole
72
Lidocaine HCl (Mouth-Throat)
179
Leucovorin Calcium
79
Lidocaine in D5W
Leukine
163
28,29
Lidocaine w/ Epinephrine
167,168
Leuprolide Acetate
72
Lidocaine-Prilocaine
135
Leuprolide Acetate (3 Month)
72
Lidocaine-Tetracaine
135
72
Linagliptin
47
72
Linagliptin-Metformin HCl
46
Lincocin
25
Lincomycin HCl
25
Leuprolide Acetate (CPP)
Leuprolide Acetate (CPP) (3 Month)
144,145
144
Levalbuterol HCl
32
Lindane
135
Levalbuterol Tartrate
33
Linezolid
25
Levatol
102
Levemir
49
Liraglutide
48
Levemir FlexPen
49
Lisdexamfetamine Dimesylate
3,4
Levetiracetam
37
Lisinopril
Levobunolol HCl
Levocetirizine Dihydrochloride
211
56
Liothyronine Sodium
231,232
60,61
Lisinopril & Hydrochlorothiazide
64
Lithium
84
Levofloxacin
150
Lithium Carbonate
84
Levofloxacin (Ophth)
213
Livalo
58
Levofloxacin in D5W
150
Lo Loestrin Fe
PAGE 262
114
Lo Minastrin Fe
114
Marnatal-F
Lodoxamide Tromethamine
215
Marplan
41
Loestrin 24 Fe
114
Marqibo
81
Lomitapide Mesylate
59
Matulane
78
Lomustine
68
Maxair Autohaler
32
Loperamide HCl
51
Maxidex
214
Lopinavir-Ritonavir
92
Maxinate
191
Lorazepam
28
Maxipime
111
Measles, Mumps & Rubella Virus Vaccines
241
Lorzone
208
191
Losartan Potassium
62
Measles-Mumps-Rubella-Varicella Virus Vaccines 241
Losartan Potassium & Hydrochlorothiazide
64
Mebendazole
22
Lotemax
214
Mecasermin
144
Loteprednol Etabonate
214
Mechlorethamine HCl
Lotronex
152
Mechlorethamine HCl (Topical)
Lovastatin
Loxapine Succinate
58,59
87
68
129
Meclizine HCl
53
Meclofenamate Sodium
10
Lozi-Flur
176
Medical Provider EZ Flu PF
241
Lubiprostone
151
Medical Provider EZ Flu Shot
241
Lucentis
212
Medrol
119
Lumigan
216
Medroxyprogesterone Acetate
224
Lumizyme
145
Medroxyprogesterone Acetate (Contraceptive)
117
Lunesta
166
Mefenamic Acid
10
72
Mefloquine HCl
66
Lupron Depot
Lupron Depot-Ped
Lurasidone HCl
144,145
84,85
Megace ES
224
Megestrol Acetate
72,73
Lutropin Alfa
141
Megestrol Acetate (Appetite)
Luveris
141
Mekinist
Luxiq
133
Meloxicam
10,26
Lyrica
37,38
Melphalan
67
Melphalan HCl
68
Memantine HCl
225
Menactra
239
Lysodren
72
M
224
76
M-M-R II
241
Menest
149
M-Vit
191
Menhibrix
239
Macitentan
107
Meningococcal (A,C,Y&W-135) Oligosaccharide
Macnatal CN DHA
191
Conjugate Vac
Macugen
212
Meningococcal (A,C,Y&W-135) Polysaccharide
Mafenide Acetate
130
Conjugate Vaccine
Makena
224
Meningococcal (C & Y)-Haemophilus B Tetanus Tox
Malathion
135
Conj Vaccine
239
Meningococcal Vac A,C,Y&W-135
239
Maprotiline HCl
PAGE 263
41
239
239
Menomune
239
Metolazone
Menostar
149
Metoprolol & Hydrochlorothiazide
Menotropins
141
Metoprolol Succinate
101
Mentax
128
Metoprolol Tartrate
101
Menveo
239
Metreleptin
145
Meperidine HCl
Mephyton
13
244
139
Metronidazole
64
22,23
Metronidazole in NaCl
23
Meprobamate
27
Mexiletine HCl
29
Mercaptopurine
70
Miconazole 3
242
Miconazole Nitrate Vaginal
242
Mesalamine
151,152
Mesna
79
MICRhoGAM Ultra-Filtered Plus
220
Mesnex
79
Midodrine HCl
244
Mestinon
66
Mifepristone (Hyperglycemia)
Metaproterenol Sulfate
32
Migergot
Metaxalone
208
47
172
Miglitol
45
Metformin HCl
47
Millipred
120
Methadone HCl
13
Millipred DP
120
Millipred DP 12-Day
120
Methamphetamine HCl
3
Methazolamide
137
Milnacipran HCl
226
Methenamine Hippurate
237
Minastrin 24 Fe
114
Methenamine Mandelate
237
Minocycline HCl
230
Methimazole
230
Minocycline HCl (Subgingival)
179
Methitest
21
Minoxidil
66
57
Methocarbamol
208
Mipomersen Sodium
Methotrexate (Antirheumatic)
8,9
Mirena
Methotrexate Sodium
Methotrexate Sodium (Antirheumatic)
Methoxsalen
Methoxsalen (Photopheresis)
117
70,71
Mirtazapine
40
9
Misoprostol
237
Mitomycin (Ophthalmic)
213
Mitosol
213
129
78
Methoxsalen (Topical)
135
Mitotane
72
Methscopolamine Bromide
235
Modafinil
6
Methyldopa
62
Moderiba
95
Methyldopa & Hydrochlorothiazide
64
Moderiba 1200 Dose Pack
95
5
Moderiba 800 Dose Pack
95
Methylin
Methylnaltrexone Bromide
152
Moexipril HCl
61
Methylphenidate HCl
5,6
Moexipril-Hydrochlorothiazide
64
Methylprednisolone
119,120
Mometasone Furoate
Methylprednisolone Acetate
118,119
Mometasone Furoate (Inhalation)
Methylprednisolone Sod Succ
Methyltestosterone
Metoclopramide HCl
PAGE 264
118,119,121
21
151
133
Mometasone Furoate (Nasal)
30
210
Mometasone Furoate-Formoterol Fumarate
Dihydrate
32
Moms Choice Rx
191
Nabumetone
Monoclate-P
158
Nadolol
102
Mononine
158
Nafarelin Acetate
145
Naftifine HCl
128
Naftin
128
Montelukast Sodium
Monurol
Morphine Sulfate
Morphine Sulfate Beads
Motofen
30
237
14
13,14
52
10
Naloxone HCl
52
Naltrexone
52
Naltrexone HCl
52
MoviPrep
167
Namenda
225
Moxifloxacin HCl
150
Namenda Titration Pak
225
Moxifloxacin HCl (Ophth)
213
Namenda XR
225
Moxifloxacin HCl in Sodium Chloride
149
Naphazoline HCl
213
Mozobil
165
Naproxen
10
Multaq
29
Naproxen Sodium
10
Multi-Nate 30
191
Naratriptan HCl
172
Multi-Nate 30 DHA
191
Nasonex
210
Multi-Nate DHA Extra
191
Nata Komplete
192
Multichew
182
NataChew
192
NataFort
192
Natal-V RX
192
Multiple Vitamins w/ Minerals & Calcium-Folic
Acid
181,182
Multiple Vitamins w/ Minerals & Folic Acid
182
Natalizumab
227
Mupirocin
127
NatalVirt 90 DHA
192
Mupirocin Calcium
209
NatalVirt CA
192
Mupirocin Calcium (Topical)
127
Natalvit
192
106,107
Natazia
114
Muse
Mustargen
Myalept
Mycophenolate Mofetil
Mycophenolate Sodium
MyKidz Iron FL
68
Nateglinide
50
145
Natelle EZ
192
Natelle ONE
192
Natelle-ez
193
Nature-Throid
232
98,99
99
183
Myleran
68
Mynatal
192
Navatab + DHA
193
Mynatal Advance
191
Nebivolol HCl
101
Mynate 90 Plus
192
Nebupent
Myobloc
210
Nebusal
122
Necon 1/50 (28)
114
Necon 10/11 (28)
114
Na Sulfate-K Sulfate-Mg Sulfate & PEG3350-NaCl-Na
Nedocromil Sodium (Ophth)
215
Bicarb-KCl
167
Neevo
193
Nabi-HB
220
Neevo DHA
193
Nabilone
53
N
PAGE 265
Navane
Nefazodone HCl
90
23
42
Nelarabine
69
Nimodipine
Nelfinavir Mesylate
94
Nipent
Neo-Fradin
7
105
78
Nisoldipine
105
NeoBenz Micro Plus Pack
125
Nitazoxanide
NeoBenz Micro SD
125
Nitisinone
145
Nitro-Bid
26
Neomycin Sulfate
7
24
Neomycin-Bacitracin Zn-Polymyxin
213
Nitrofurantoin Macrocrystal
237
Neomycin-Colistin-HC-Thonzonium
217
Nitrofurantoin Monohyd Macro
237
Neomycin-Polymy-Dexameth
214,215
Nitroglycerin
26,27
Neomycin-Polymyxin-Gramicidin
213
Nitroglycerin (Intra-Anal)
22
Neomycin-Polymyxin-HC (Ophth)
214
Nitrostat
27
Neomycin-Polymyxin-HC (Otic)
216,217
Nizatidine
235
Nepafenac
216
Norditropin
143
Nephplex Rx
180
Norditropin FlexPro
143
Nephrocaps QT
180
Norditropin NordiFlex Pen
143
Nestabs
193
Norelgestromin-Ethinyl Estradiol
117
Nestabs ABC
193
Norethin Acet & Estrad-Fe
Nestabs DHA
193
Norethindrone & Eth
Neulasta
163
Estradiol
Neumega
163
Norethindrone & Ethinyl Estradiol-Fe
113,116
Neupogen
163,164
Norethindrone & Mestranol
114,115
83
Norethindrone (Contraceptive)
117,118
216
Norethindrone Acet & Eth Estra
Neupro
Nevanac
Nevirapine
93,94
113,114,115
111,112,113,114,115,116
113,114,115
Norethindrone Acetate
224
116
Newgen
193
Norethindrone Acetate-Ethinyl Estradiol-Fe
Nexa Plus
193
Norethindrone Acetate-Ethinyl Estradiol-Fe Fum
Nexa Select
193
(Biphasic)
114
Norethindrone-Eth Estradiol (Biphasic)
114
NexAVAR
NexIUM
Nexplanon
Niacin (Antihyperlipidemic)
76
236,237
Norethindrone-Eth Estradiol
117
(Triphasic)
111,112,113,115
60,244
Norfloxacin
150
Niacin-Lovastatin
58
Norgestimate-Ethinyl Estradiol
Niacin-Simvastatin
59
Norgestimate-Ethinyl Estradiol (Triphasic)
Nicardipine HCl
103,105
Norgestrel & Ethinyl Estradiol
112,114,115,116
115,116
112,114,115
Nicotine
228
Norinyl 1+50 (28)
115
Nicotrol
228
Normosol-R in D5W
175
Nicotrol NS
228
Noroxin
150
Nifedipine
102,103,105
Nortriptyline HCl
45
Nilandron
73
Norvir
93
Nilotinib HCl
77
NovoLIN 70/30
50
Nilutamide
73
NovoLIN 70/30 ReliOn
50
PAGE 266
NovoLIN N
50
OB Complete/DHA
194
NovoLIN N ReliOn
50
OB-Natal One
194
NovoLIN R
50
Obstetrix DHA
194
NovoLIN R ReliOn
50
Obstetrix EC
194
NovoLOG
50
Octagam
220
NovoLOG FlexPen
50
Octreotide Acetate
146
NovoLOG Mix 70/30
50
Ofatumumab
NovoLOG Mix 70/30 FlexPen
50
Ofloxacin
150
NovoLOG PenFill
50
Ofloxacin (Ophth)
213
Ofloxacin (Otic)
216
NovoSeven RT
158
Noxafil
55
Nplate
164
Nucynta
Nucynta ER
14,15
14
71
Oforta
70
Ogestrel
115
Olanzapine
88
Olanzapine Pamoate
88
Nuedexta
227
Oleptro
Nutri-Tab OB
193
Olmesartan Medoxomil
61
Nutri-Tab OB + DHA
193
Olmesartan Medoxomil-Hydrochlorothiazide
63
Nutrivit
180
Olopatadine HCl
216
Nutropin
144
Olsalazine Sodium
151
Nutropin AQ
144
Olysio
95
Nutropin AQ NuSpin 10
143
Omacetaxine Mepesuccinate
78
143
Omalizumab
29
143
Omega-3-acid Ethyl Esters
57
Nutropin AQ Pen
143
Omeprazole
NuvaRing
117
Omeprazole+Syrspend SF Alka
237
Omniflex Diaphragm
170
Omnitrope
144
Nuvigil
Nystatin
6
54,242
42,43
236,237
Nystatin (Mouth-Throat)
179
OnabotulinumtoxinA
210
Nystatin (Topical)
128
OnabotulinumtoxinA (Cosmetic)
134
Nystatin Vaginal
242
Oncaspar
77
Nystatin-Triamcinolone
128
Ondansetron
53
Ondansetron HCl
O
52,53
Ondansetron HCl and Dextrose
53
O-Cal FA
193
Ondansetron HCl and Sodium Chloride
53
O-Cal Prenatal
194
Ondansetron HCl-Dextrose
53
OB Complete
194
Ondansetron HCl-NaCl
53
OB Complete 400
194
Onglyza
47
OB Complete One
194
Ontak
78
OB Complete Petite
194
Opana ER
15,16
OB Complete Premier
194
Oprelvekin
163
OB Complete with DHA
194
Opsumit
107
PAGE 267
Orap
228
Pancreaze
Orapred ODT
120
Pancrelipase (Lipase-Protease-Amylase)
Orencia
11
Orfadin
145
Orlistat
4
136
136,137
Panitumumab
71
Pantoprazole Sodium
237
Paragard Intrauterine Copper
117
145
Orphenadrine Citrate
208
Paricalcitol
Ortho Diaphragm All-Flex
170
Paromomycin Sulfate
Ortho Tri-Cyclen Lo
115
Paroxetine HCl
42
OrthoVisc
209
Paser
67
Oseltamivir Phosphate
OsmoPrep
7
97
Pataday
216
167
Patanol
216
Otezla
11
Paxil
42
Otrexup
8,9
Pazopanib HCl
77
Ovcon-50
115
PCE
Ovidrel
141
Ped Multivitamins w/Fl & Iron
170
182,183
Oxaliplatin
68
Pediarix
234
Oxandrolone
20
Pediatric Multivitamins w/Fl
Oxaprozin
11
Pediatric Vitamins ACD & L-Methylfolate w/
Oxcarbazepine
38
Fluoride
185
183,184,185
Oxiconazole Nitrate
128
Pediatric Vitamins ACD Fluoride & Iron
183
Oxistat
128
Pediatric Vitamins ACD w/ Fluoride
185
Oxsoralen
135
Pedipirox-4 Nail
128
Oxybutynin Chloride
238
Pedvax HIB
239
Oxycodone HCl
16
PEG 3350-KCl-NaCl-Na Sulfate-Na Ascorbate-
Oxycodone w/ Acetaminophen
19
Ascorbic Acid
Oxycodone-Ibuprofen
19
PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod
OxyCONTIN
16
Sulfate
Oxymetholone
20
PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod
Oxymorphone HCl
Ozurdex
15,16,17
215
167
166,167
Chloride
167
Peg-Intron
95
Pegaptanib Sodium
P
212
Pegaspargase
77
Paclitaxel
81
Pegasys
95,96
Paclitaxel Protein-Bound Particles
79
Pegasys ProClick
95,96
Paire OB
194
Palifermin
78
Peginterferon alfa-2a
95,96
Paliperidone
86
Peginterferon alfa-2b
95
Peginterferon alfa-2b (Antineoplastic)
78
Paliperidone Palmitate
Palivizumab
Palonosetron HCl
Pamidronate Disodium
PAGE 268
85,86
221
52
139,140
Pegfilgrastim
163
Pegloticase
154
Pegvisomant
141
Pemetrexed Disodium
69
Penbutolol Sulfate
102
Phytonadione
Penciclovir
130
Picato
Penicillamine
97
244
128,129
Pilocarpine HCl
212
Penicillin G Benzathine
222
Pilocarpine HCl (Oral)
Penicillin G Benzathine & Procaine
223
Pimecrolimus
134
Penicillin G Pot in Dextrose
222
Pimozide
228
Pindolol
102
Penicillin G Potassium
222,223
179,180
Penicillin G Procaine
223
Pioglitazone HCl
48
Penicillin G Sodium
223
Pioglitazone HCl-Metformin HCl
46
Penicillin V Potassium
223
Pirbuterol Acetate
32
Pentacel
234
Piroxicam
11
Pentam
23
Pitavastatin Calcium
58
Pentamidine Isethionate
23
Plasma-Lyte-56 in D5W
175
Plerixafor
165
Pneumococcal 13-Valent Conjugate Vaccine
239
Pneumococcal Vac Polyvalent
239
Pneumovax 23
239
PNV Folic Acid + Iron
195
Pentasa
Pentazocine w/ Naloxone
Pentosan Polysulfate Sodium
Pentostatin
Pentoxifylline
151,152
20
154
78
160
Perforomist
32
PNV OB+DHA
195
Perindopril Erbumine
61
PNV Prenatal Plus Multivitamin
195
PNV Tabs 29-1
195
PNV-DHA
195
PNV-DHA+Docusate
195
PNV-First
195
226
PNV-OB/DHA
195
71
PNV-Omega
195
Pertzye
136
PNV-Select
195
Phenazopyridine HCl
154
PNV-Total
195
41
Podofilox
134
Peritoneal Dialysis Solutions
Perjeta
Permethrin
Perphenazine
Perphenazine-Amitriptyline
Pertuzumab
Phenelzine Sulfate
99,100
71
135
89
Phenobarbital
165,166
Poliovirus Vaccine, IPV
241
PHENobarbital
165,166
Poly-Vi-Flor
184
Poly-Vi-Flor/Iron
183
Phenoxybenzamine HCl
61
Phentermine HCl
4
Poly-Vitamin/Fluoride/Iron
183
Phentermine HCl-Topiramate
4
Polyethylene Glycol 3350
167
Phenyleph-Promethazine w/ Cod
121,122
Polymyxin B Sulfate
25
Phenytoin
39,40
Pomalidomide
73
Phenytoin Sodium Extended
39,40
Pomalyst
73
Ponatinib HCl
75
Porfimer Sodium
78
Posaconazole
55
Phisohex
90
Phoslyra
152
Photofrin
78
Physicians EZ Use Flu
PAGE 269
241
Potassium Acetate
177
Potassium Bicarbonate
Potassium Chloride
177
177,178
Premarin
149,242
Premphase
147
Prempro
147
Potassium Chloride in D5W Lactated Ringers 174,175
Prena1
196
Potassium Chloride in Dextrose
Prena1 Pearl
196
Potassium Chloride in Dextrose & Sodium Chloride 175
Prena1 Plus/Quatrefolic
196
Potassium Chloride Microencapsulated Crystals
Prena1/Quatrefolic
196
Potassium Chloride ER
178
175,176
CR
177
PrenaCare
196
Potassium Citrate (Alkalinizer)
153
PrenaFirst
196
Potassium Citrate ER
153
Prenaissance
197
Potassium Citrate-Citric Acid
153
Prenaissance 90 DHA
196
Potassium Phosphate Dibasic
177
Prenaissance Balance
197
PR Natal 400
195
Prenaissance DHA
197
PR Natal 400 ec
195
Prenaissance Harmony DHA
197
PR Natal 430
196
Prenaissance Next
197
PR Natal 430 ec
195
Prenaissance Next-B
197
PR Natal 440 ec
196
Prenaissance Plus
197
Pradaxa
36
Prenaissance Promise
197
Pralatrexate
70
PrenaPlus
197
Pramipexole Dihydrochloride
83
Prenat Vit w/ Iron Carbonyl-Fe Asp Glyc-FA-Omega
Pramlintide Acetate
46
Fatty Acid
194
PreNata
197
46
Prenatabs FA
197
161
Prenatabs Rx
197
198
Pramoxine-HC
PrandiMet
Prasugrel HCl
132
Pravastatin Sodium
59
Prenatal
Praziquantel
22
Prenatal 19
197,198
Prazosin HCl
62,63
Prenatal AD
198
Pred Mild
215
Prenatal Formula
198
Prednicarbate
133
Prenatal Low Iron
198
Prednisolone
120
Prenatal Multivit-Min w/Fe-FA
192
Prednisolone Acetate (Ophth)
215
Prenatal Multivitamins & Minerals w/ L-Methylfolate-
Prednisolone Sodium Phosphate
118,120,121
FA
199
PrednisoLONE Sodium Phosphate
120
Prenatal MV & Min w/ Ferrous Fumarate-L
Prednisolone Sodium Phosphate (Ophth)
215
Methylfolate-DHA
Prednisone
120,121
186
Prenatal MV & Min w/Fe Bisglyc-Fe Prot Succ-FA-CA-
PredniSONE Intensol
120
Omega 3
Prefera OB
196
Prenatal MV & Min w/Fe Bisglycinate-FA-DHA 193,206
Prefera OB + DHA
196
Prenatal MV & Min w/Fe Carbonyl-Docusate-Folic
PreferaOB One
196
Acid-DHA
PreFol-DHA
196
Prenatal MV & Min w/Fe Carbonyl-FA-DHA
Pregabalin
PAGE 270
187,191,195,196,201,202,203
200
200,203
37,38
Prenatal MV & Min w/Fe Fumarate-FADHA
Prenatal Vit w/ Ferrous Fumarate-Folic
190,195,206
Acid186,187,191,192,193,194,195,196,197,198,199,20
Prenatal MV & Min w/Fe Polysaccharide Complex-FA-
0,201,203,204,205,206,207
DHA
Prenatal Vit w/ Ferrous Fumarate-L Methylfolate-FA-
187,195,200,201,202,206
Prenatal MV & Min w/o Vit A w/FE Polysac Cmplx-FA-
DHA
190,191
CA-Omega 3
193
Prenatal Vit w/ Ferrous Fumarate-L Methylfolate-Folic
Prenatal MV & MIN-FE-FA-DHA
198
Acid
Prenatal Plus
198
Prenatal Vit w/ Iron Carbonyl-Fe Aspart Glyc-FA-
Prenatal Plus Iron
198
Omega 3
Prenatal Plus/Iron
198
Prenatal Vit w/ Iron Carbonyl-Fe Aspart Glycinate-
195,199,205,208
186,189,194,203
Prenatal Vit w/ Docusate-Fe Fumarate-Folic
FA
Acid
Prenatal Vit w/ Iron Carbonyl-Fe Gluconate-Folic
192,195,198,201
194
Prenatal Vit w/ Docusate-Iron Carbonyl-Folic
Acid
Acid
Prenatal Vit w/ Iron Carbonyl-Folic
185,190,191,192,194,196,198,202,203,204,205
204
Prenatal Vit w/ Fe Bisglycinate Chelate-Folic
Acid
Acid
Prenatal Vit w/ Iron Polysaccharide Cmplx-L
192,204,205,206
189,192,194,195,197,198,200,207
Prenatal Vit w/ Fe Bisglycinate-Fe Protein Succ-Folic
Methylfolate-FA
Acid
Prenatal Vit w/ Iron Polysaccharide Complex-Folic
191
191,193,201
Prenatal Vit w/ Fe Carbonyl-Fe Bisglycinate-FA-Fish
Acid
Oil
Prenatal Vit w/ Selenium-Fe Fumarate-Folic Acid
189,194,195
189,201
205
Prenatal Vit w/ Fe Fum-Fe Bisglycinate Chelate-Folic
Prenatal Vit w/ Sodium Feredetate-Folic Acid-Omega
Acid
3
192
186,196
Prenatal Vit w/ Fe Fum-Iron Polysacch Complex -FA-
Prenatal Vit w/Polysaccharide Fe-FA-Fish Oil
Omega 3
Prenatal Vit without Vit A w/ Fe Bisglycinate-FA-Omeg
187,188,201,202
Prenatal Vit w/ Fe Gluconate-Fe Fumarate-Folic
Acid
3
191
193,202,204
Prenatal Vit without Vit A w/ Fe Bisglycinate-Folic
Prenatal Vit w/ Fe Poly Cmplx-Fe Heme Polypept-FA &
Acid
Omega 3
PreNatal Vitamins Plus
190,196,207
200
193,204
198
Prenatal Vit w/ Fe Polysacch Cmplx-Fe Asp-Fe Glyc-
Prenatal w/ Calcium Carbonate-Vit B6-Vit B12-Folic
FA & DHA
Acid
194,203
186,189,200,203
Prenatal Vit w/ Fe Polysacch Cmplx-Fe Heme
Prenatal w/ Calcium-Vit B6-Folic Acid-
Polypept-FA & DHA
Ginger
196,198,207
Prenatal Vit w/ Fe Polysacch Complex-Fe Asp-Fe
Glyc-FA
185,189,197,207,208
Prenatal w/ Calcium-Vit B6-Vit B12-Folic Acid189
Ginger
199
Prenatal Vit w/ Fe Polysacch Complex-Fe Heme
Prenatal w/ Fe Carbonyl-Fe Asp-Fe Glyc-FA-Omega
Polypeptide-FA
Fatty Acids
190,196,207
189
Prenatal Vit w/ Fe Polysacch Complex-L Methylfolate-
Prenatal w/ Vit B2-B6-B12-Cholecalciferol-Folic
FA-DHA
Acid
206
196,206
Prenatal Vit w/ Ferrous Fumarate-FA-Omega 3 Fatty
Prenatal w/ Vit B2-B6-B12-Cholecalciferol-L
Acids
Methylfolate-FA
PAGE 271
186,189,194,200,201,207
196,206
Prenatal w/Fe Carbonyl-FA-DSS-Omega 3 Fatty
Acids
Prenatal without A w/ Fe Asparto Glyc-Docusate-Folic
194
Acid
205
Prenatal w/Fe Cbnyl-Fe Asparto Glyc-FA-DSS-Omega
Prenatal without A w/ Fe Carbonyl-Docusate-Folic
3
189,204
Acid
Prenatal w/Fe Fumarate-FA-DSS-Fish Oil
202,203
Prenatal without A w/ Fe Carbonyl-L Methylfolate-FA-
187
Prenatal w/Fe Polysacch Cmplx-Sod Feredetate-FA-
DHA
Omega 3
Prenatal without A w/ Fe Chelate-L Methylfolate-FA-
186,188,189,191,197,204,205
199
Prenatal w/o A Vit w/ Fe Fumarate-L Methylfolate-Folic
DHA
Acid
Prenatal without A w/ Fe Fumarate-L Methylfolate-FA-
206
196,206
Prenatal w/o A w/ Fe Asparto Glyc-L Methylfolate-FA-
DHA
DHA
199
195,196,199,205,206,208
Prenatal w/o Vit A w/ Fe Carbonyl-DSS-FA-
Omega 3
DHA
187,190,191,197,200,207,208
195,199,205,208
Prenatal w/o Vit A w/ Fe Carbonyl-Fe Aspart Glyc-FA-
Omegas
DHA
Prenatal without A w/ Fe Fumarate-Sod Feredetate-
194
193,205
FA-DHA
Fish Oil
Prenatal without Vit A w/ Fe Carbonyl-Fe Gluc-
194
196,206
Docusate-FA
Omega 3
Prenatal without Vit A w/ Fe Fum-FA-Omega Fatty
194
187,202,204
Prenatal w/o Vit A w/ Fe Carbonyl-Fe Gluconate-DSS-
Acids
FA-DHA
Prenatal without Vit A w/ Fe Fumarate-FA-Fish Oil 202
187,188,192,195,196,197,198,200
186,190,192,203
Prenatal w/o Vit A w/ Fe Carbonyl-Fe Gluconate-FA &
Prenatal without Vit A w/ Fe Fumarate-L Methylfolate-
Vit B6
Omegas
187,204
Prenatal w/o Vit A w/ Fe Carbonyl-Folic AcidDHA
193,205
Prenatal without Vit A w/ Iron Carbonyl-Folic Acid & Vit
185,200
B6
202
Prenatal w/o Vit A w/ Fe Fumarate-DSS-FA-
Prenatal without Vit A w/ Iron Polysaccharide Complex-
DHA
FA
191
Prenatal w/o Vit A w/ Fe Fumarate-Fe Carbonyl-DSS-
Prenatal+DHA
198
FA-DHA
Prenatal-U
198
Prenate
199
Prenatal w/o Vit A w/Fe Fumarate-Docusate Ca-Folic
Prenate AM
199
Acid-DHA
Prenate DHA
199
Prenatal without A Vit w/ Fe Carbonyl-Fe Fumarate-
Prenate Elite
199
Folic Acid
Prenate Enhance
199
Prenatal without A Vit w/ Fe Fum-Iron Polysacch
Prenate Essential
199
Complex -FA
Prenate Mini
199
Prenatal without A Vit w/ Fe Fumarate-Folic
Prenate Restore
199
Acid
PreNexa
199
PreNexa Premier
199
Prenatal without A w/ Fe Asp Glyc-L Methylfolate-FA-
Prentif Fitting Set
170
Omega 3
PrePLUS
199
189,190,193,195,196,197,199,202,203,204,205
187,207
Prenatal w/o Vit A w/ Iron-FA-DHA
186
189,193,202
192
188,190,200,201,205
186,190,197,198,201,203,204,207
Prenatal without A Vit w/ Iron Carbonyl-Folic Acid
PAGE 272
207
199
PreQue 10
200
Propylthiouracil
230
PreTAB
200
ProQuad
241
Previte Rx
200
ProtectBone
181
Prevnar 13
239
ProtectNatal
200
Prezista
93
Protein C Concentrate (Human)
160
Prialt
12
Protopic
134
Primaquine Phosphate
66
Protriptyline HCl
45
Primidone
38
Proventil HFA
32
Pristiq
43
Provida OB
200
221
Prudoxin
129
ProAir HFA
32
Pulmicort
31
Probenecid
154
Pulmicort Flexhaler
31
Privigen
Procarbazine HCl
Prochieve
78
243
Pulmozyme
229
PureFe OB Plus
200
Prochlorperazine
89
Pyrazinamide
67
Prochlorperazine Edisylate
89
Pyridostigmine Bromide
66
Prochlorperazine Maleate
89
Pyrimethamine
66
Procrit
164
Procysbi
153
Q
Profilnine SD
158
Qsymia
Progesterone (Vaginal)
Progesterone Micronized
242,243
224
4
Quartette
115
Quetiapine Fumarate
88
Proglycem
47
Quflora Pediatric
184,185
Prograf
99
Quinapril HCl
Proleukin
78
Quinapril-Hydrochlorothiazide
61
64,65
Prolia
140
Quinine Sulfate
Promacta
164
Qutenza
135
Promar
181
Qutenza (2 Patch)
135
Promethazine & Phenylephrine
121,122
66
Qvar
31
Promethazine HCl
56
Promethazine VC
121
R
Promethazine VC Plain
121
R-Natal OB
Promethazine VC/Codeine
122
Rabeprazole Sodium
Promethazine w/Codeine
122
Rabies Immune Globulin (Human)
220
Promethazine-DM
122
Raloxifene HCl
144
Promethazine-Phenylephrine
122
Raltegravir Potassium
Propafenone HCl
29
Proparacaine HCl
214
Propranolol & Hydrochlorothiazide
Propranolol HCl
Propranolol HCl Sustained-Release Beads
PAGE 273
64
102
101,102
Ramelteon
200
236,237
92
166
Ramipril
61
Ramucirumab
71
Ranexa
Ranibizumab
25,26
212
Ranitidine HCl
235,236
Retisert
215
25,26
Retrovir
93
154
Revatio
108
Rapamune
99
Revlimid
98
Rasagiline Mesylate
84
Reyataz
93
Ranolazine
Rapaflo
Ravicti
145
Rheumatrex
RE DualVit OB
200
Rhinocort Aqua
RE OB + 90 DHA
200
Rho D Immune Globulin (Human)
RE OB + DHA
200
RhoGAM Ultra-Filtered Plus
221
RE Prenatal Multivitamin/Iron
200
Rhophylac
221
RE-Nata 29 OB
200
RiaSTAP
159
Reaphirm
200
Ribasphere
96
Ribasphere RibaPak
96
96
Rebetol
96
9
210
220,221
Rebif
227
RibaTab
Rebif Rebidose
227
Ribavirin (Hepatitis C)
Rebif Rebidose Titration Pack
227
Rifabutin
67
Rebif Titration Pack
227
Rifampin
67
Recombinate
158
Rifaximin
23
Recombivax HB
241
Rilpivirine HCl
91
95,96
Rectiv
22
Riluzole
210
Regonol
66
RimabotulinumtoxinB
210
Regranex
136
Rimantadine Hydrochloride
97
Relenza Diskhaler
97
Rimexolone
215
ReliOn 70/30
50
Riomet
47
ReliOn N
50
RisperDAL Consta
86
ReliOn R
50
Risperidone
86,87
Relistor
152
Risperidone Microspheres
86
Relnate DHA
200
Ritonavir
93
Relpax
172
Rituxan
71
Remicade
152
Rituximab
71
Remodulin
107
Rivaroxaban
34
Renagel
153
Rivastigmine
225
Renax
182
Rivastigmine Tartrate
Renvela
153
Rixubis
159
ReoPro
161
Rizatriptan Benzoate
173
Repaglinide
Repaglinide-Metformin HCl
225,226
50,51
Romidepsin
76
46
Romiplostim
164
Repronex
141
Rescriptor
93
Rosiglitazone Maleate
48
Restasis
213
Rosuvastatin Calcium
58
Retapamulin
127
Rotarix
PAGE 274
Ropinirole Hydrochloride
83,84
241
RotaTeq
241
SEROquel XR
Rotavirus Vaccine, Live Oral
241
Serostim
144
Rotavirus Vaccine, Live Oral Pentavalent
241
Sertaconazole Nitrate
127
Rotigotine
83
Rozerem
166
Ruxolitinib Phosphate
76
S
Sabril
39
88
Sertraline HCl
42
SetonET
201
SetonET-EC
201
Sevelamer Carbonate
153
Sevelamer HCl
153
SfRowasa
152
Sacrosidase
137
Sildenafil Citrate
107
Safyral
116
Sildenafil Citrate (Pulmonary Hypertension)
108
Saizen
144
Silodosin
154
Saizen Click.Easy
144
Silver Sulfadiazine
130
Sal-Tropine
235
Simcor
59
Salicylic Acid
134
Simeprevir Sodium
95
Salmeterol Xinafoate
Samsca
SandIMMUNE
32
Simponi
8
146
Simponi Aria
8
99
Simvastatin
59
SandoSTATIN LAR Depot
146
Sinecatechins
Santyl
134
Sirolimus
99
Sitagliptin Phosphate
47
Sitagliptin-Metformin HCl
46
Saphris
Sapropterin Dihydrochloride
Saquinavir Mesylate
88
145
126
92
Skelid
140
Sargramostim
163
Skyla
117
Savella
226
SM B-Complex/Vitamin C
181
Savella Titration Pack
226
Sodium Chloride
178
Saxagliptin HCl
47
Sodium Chloride (GU Irrigant)
153
Scopolamine
53
Sodium Chloride (Inhalant)
122
Scopolamine HBr
235
Sodium Chloride Flush
178
Se-Care
201
Sodium Ferric Gluconate Complex in Sucrose
165
Se-Care Conceive
201
Sodium Fluoride
Se-Natal 19
201
Sodium Fluoride (Dental)
179
Se-Natal 90
201
Sodium Fluoride-Xylitol
176
Se-Plete DHA
201
Sodium Hyaluronate (Viscosupplement)
209
Se-Tan DHA
201
Sodium Oxybate
224
Select-OB
201
Sodium Phenylbutyrate
145
Select-OB+DHA
201
Sodium Phosphate Monobasic-Sodium Phosphate
176,177
Selegiline
41
Dibasic
167
Selegiline HCl
84
Sodium Polystyrene Sulfonate
100
Selenium Sulfide
130
Serevent Diskus
32
PAGE 275
Sodium Sulfate-Potassium Sulfate-Magnesium
Sulfate
167
Sofosbuvir
96
Sulfadiazine
Solesta
98
Sulfamethoxazole-Trimethoprim
Solifenacin Succinate
238
Sulfasalazine
Soliris
160
Sulindac
Soltamox
73
229
24
152
11
Sumatriptan
173
Solu-CORTEF
121
Sumatriptan Succinate
172,173
Solu-MEDROL
121
SUMAtriptan Succinate
173
Soma
209
Sunitinib Malate
Somatropin
142,143,144
76
Supartz
209
Somatropin (Non-Refrigerated)
144
Supervite
181
Somavert
141
Supervite EC
182
76
Supprelin LA
145
Sorafenib Tosylate
Soriatane
129
Suprax
110
Sotalol HCl
102
Suprep Bowel Prep
167
Sotalol HCl (AFIB/AFL)
102
Sustiva
94
96
Sutent
76
Sylatron
78
Sovaldi
Spinosad
135
Spiriva HandiHaler
30
Symbicort
32,33
Spironolactone
138
Symlin
46
Spironolactone & Hydrochlorothiazide
137
SymlinPen 120
46
Sporanox
55
SymlinPen 60
46
Sprycel
76
Synagex
182
93,94
Synagis
221
146
Synarel
145
SynaTek
182
Stavudine
Stimate
Strattera
5
Streptozocin
69
Synera
135
Stribild
94
Synribo
78
Stromectol
22
Synvisc
209
Suboxone
20
Synvisc One
209
Succimer
52
Syprine
Suclear
167
Sucraid
137
T
Sucralfate
236
Taclonex
Sulconazole Nitrate
127
Tacrolimus
97
133
98,99
Sulfacetamide Sod-Prednisolone
214,215
Tacrolimus (Topical)
134
Sulfacetamide Sodium
129,130
Tadalafil
106
Sulfacetamide Sodium (Acne)
125,126
Tadalafil (Pulmonary Hypertension)
108
Sulfacetamide Sodium (Ophth)
Sulfacetamide Sodium w/ Sulfur
213
123,124,125,126
Tafinlar
Tafluprost
216
161
Sulfacetamide Sodium-Sulfur w/ Skin Cleanser
125
Taliglucerase Alfa
Sulfacetamide-Prednisolone
215
Tamiflu
PAGE 276
77
97
Tamoxifen Citrate
73
Testosterone
20,21
Tamsulosin HCl
154
Testosterone Cypionate
21
Tandem DHA
201
Testosterone Enanthate
21
Tandem OB
201
Testred
21
Tapentadol HCl
Tarceva
14,15
77
Tetanus Immune Globulin (Human)
220
Tetanus Toxoid Adsorbed
234
Targretin
78,129
Tetanus Toxoid-Diphtheria-Acellular Pertussis Adsorb
Taron-Bc
202
(Tdap)
Taron-C DHA
202
Tetanus-Diphtheria Toxoids (Td)
Taron-Duo EC
202
Tetanus-Diphtheria Toxoids Td
234
Taron-Prex
202
Tetrabenazine
226
233
233,234
Tasigna
77
Tetracycline HCl
230
Tasmar
82
Tetrahydrozoline HCl
210
Taxotere
81
Tev-Tropin
144
Tazarotene
129
Teveten
62
Tazorac
129
Theo-24
33
Tbo-Filgrastim
163
Theophylline
33
Tecfidera
227
TheraCys
78
Teduglutide (rDNA)
153
Thioridazine HCl
89
TEGretol-XR
38
Thiotepa
69
Tekturna
65
Thiothixene
90
Tekturna HCT
65
Thrombate III
160
Telaprevir
95
Thymoglobulin
99
Telavancin HCl
23
Thyrogen
Telbivudine
96
Thyroid
Telithromycin
24
Thyrotropin Alfa
Telmisartan
62
Tiagabine HCl
Telmisartan-Amlodipine
65
Ticarcillin & Pot Clavulanate
223
Telmisartan-Hydrochlorothiazide
65
Ticlopidine HCl
161
Temozolomide
68,69
136
230,232,233
136
39
Tigecycline
24
29
Temsirolimus
77
Tikosyn
Teniposide
81
Tiludronate Disodium
140
Timentin
223
Tenivac
234
Tenofovir Disoproxil Fumarate
94
Timolol
211
Terazosin HCl
63
Timolol Maleate
102
Terbinafine HCl
54
Timolol Maleate (Ophth)
Terbutaline Sulfate
33
Timoptic Ocudose
212
Terconazole Vaginal
242
Tinzaparin Sodium
36
Teriflunomide
226
Tiotropium Bromide Monohydrate
30
Teriparatide (Recombinant)
139
Tipranavir
91
Tivicay
94
Tesamorelin Acetate
PAGE 277
141,142
211,212
Tizanidine HCl
209
Travatan Z
216
TL G-Fol OS
182
Travoprost
216
TL-Assure ONE
202
Trazodone HCl
TL-Assure+DHA
202
Treanda
69
TL-Care DHA
202
Trelstar Depot
73
TL-Fluorivite
183
Trelstar Depot Mixject
73
TL-Select
202
Trelstar LA
73
TL-Select DHA
202
Trelstar LA Mixject
73
Trelstar Mixject
73
Tobi Podhaler
TobraDex
Tobramycin
7
215
7
42,43
Treprostinil
107
Treprostinil Sodium
107
Tobramycin (Ophth)
213
Tretinoin
123,126
Tobramycin Sulfate
8
Tretinoin (Chemotherapy)
Tobramycin Sulfate in Saline
7
Tretinoin Microsphere
126
Tobramycin-Dexamethasone
215
Tretten
159
Tocilizumab
9
Trexall
71
Tofacitinib Citrate
8
Tri Rx
202
78
Tolazamide
51
Tri-Tabs DHA
202
Tolbutamide
51
Tri-Vi-Flor
185
Tolcapone
82
Tri-Vi-Floro
185
Tolmetin Sodium
11
Tri-Vit/Fluoride/Iron
183
202
Tolterodine Tartrate
238
TriAdvance
Tolvaptan
146
Triamcinolone Acetonide
Topicort
133
Triamcinolone Acetonide (Mouth)
179
38
Triamcinolone Acetonide (Nasal)
210
Triamcinolone Acetonide (Topical)
133
Triamcinolone in Absorbase
133
Triamterene
138
Topiramate
Topotecan HCl
Torisel
Torsemide
81,82
77
138
119,133
Tositumomab
71
Triamterene & Hydrochlorothiazide
Totect
79
Trianex
133
Toviaz
238
TriCare
203
TriCare DHA 301
202
Tracleer
107,108
137,138
Tradjenta
47
TriCare Prenatal Compleat
202
Tramadol HCl
17
TriCare Prenatal DHA ONE
203
Tramadol-Acetaminophen
19
Trientine HCl
97
Trametinib Dimethyl Sulfoxide
76
Trifluoperazine HCl
89
Trandolapril
61
Trifluridine
213
Tranexamic Acid
165
Transderm-Scop
53
TriHIBit Preservative Free
234
Tranylcypromine Sulfate
41
Trimesis Rx
203
Trastuzumab
71
Trimethobenzamide HCl
PAGE 278
Trihexyphenidyl HCl
82
53
Trimethoprim
23
UltimateCare ONE
203
Trimipramine Maleate
45
UltimateCare ONE NF
204
Trinatal GT
203
Ultra NatalCare
204
Trinatal Ultra
203
UltraBag/Dianeal PD-2/1.5% Dex
100
Trinate
203
UltraBag/Dianeal PD-2/2.5% Dex
100
Tripedia Preservative Free
234
UltraBag/Dianeal PD-2/4.25%Dex
100
TriPhluoriVit
185
UltraBag/Dianeal/1.5% Dextrose
100
Triptorelin Pamoate
73
UltraBag/Dianeal/4.25% Dex
100
Trisenox
78
Ultresa
137
140
Triveen-Duo DHA
203
Urofollitropin Purified
Triveen-One
203
Ursodiol
150,151
Triveen-PRx RNF
203
Uvadex
78
Triveen-Ten
203
Triveen-U
203
V
Tropicamide
212
V-Natal
204
Trospium Chloride
238
V-Natal DHA
204
TRUEtest Test
136
Valacyclovir HCl
TrueTrack Blood Glucose
171
Valchlor
129
TrueTrack Glucose Control
171
Valcyte
95
TrueTrack Test
136
Valganciclovir HCl
95
Trust Natal DHA
203
Valproate Sodium
40
Valproic Acid
40
97
Truvada
94
Twinject
244
Valrubicin
74
Twinrix
241
Valsartan-Hydrochlorothiazide
65
Tygacil
24
Valstar
74
Tykerb
77
Vancomycin HCl
Tysabri
227
Vancomycin HCl in Dextrose
23
Tyvaso
107
Vantas
73
Tyvaso Refill
107
Vaqta
241
Tyvaso Starter
107
Varenicline Tartrate
228
Varicella Virus Vaccine Live
242
Varivax
242
Vectibix
71
Vectical
129
161
Tyzeka
96
Tyzine
210
U
22,23
Uceris
121
Velaglucerase Alfa
Udamin
182
Velcade
Udamin SP
182
Veletri
107
Ulesfia
135
VemaVite-PRx 2
204
Ulipristal Acetate
117
Vemurafenib
Uloric
154
Vena-Bal DHA
204
Ultimate OB DHA
203
Venatal Complete DHA
204
PAGE 279
77
77
Venatal-FA
Venlafaxine HCl
Venlafaxine HCl ER
Venofer
Ventolin HFA
Verapamil HCl
204
43,44
Vincristine Sulfate Liposome
81
Vinorelbine Tartrate
81
44
Viokace
137
165
Viracept
94
Viread
94
33
105,106
Virt-Bal DHA
205
Verdeso
133
Virt-Bal DHA Plus
205
Veregen
126
Virt-PN
205
Veripred 20
121
Virt-PN DHA
205
Verteporfin
214
Virt-PN Plus
205
VESIcare
238
Virt-Select
205
Vexol
215
Vistide
Viagra
107
Visudyne
214
Vibativ
23
Vitafol
181
230
Vitafol Ultra
206
Victoza
48
Vitafol-Nano
206
Victrelis
96
Vitafol-OB+DHA
206
Videx
94
Vitafol-One
206
Vigabatrin
39
Vitafol-Plus
206
213
Vital-D Rx
181
Vibramycin
Vigamox
95
Viibryd
43
VitaMedMD One Rx/Quatrefolic
206
Vilazodone HCl
43
VitaMedMD Plus Rx/Quatrefolic
206
VitaMedMD RediChew Rx
206
VitaPearl
206
Vimizim
145
Vimpat
38,39
Vinacal
204
VitaPhil
206
Vinacal B
204
VitaPhil + DHA
206
Vinate AZ
204
VitaSpire
207
Vinate AZ Extra
204
Viva CT Prenatal
207
Vinate C
204
Viva DHA
207
Vinate Calcium
204
Vivaglobin
221
Vinate Care
204
Vivelle-Dot
149
Vinate DHA
205
Vivitrol
Vinate DHA RF
205
Vol-Nate
207
Vinate GT
205
Vol-Plus
207
Vinate IC
205
Vol-Tab Rx
207
Vinate II
205
Voltaren
127
Vinate M
205
Voraxaze
79
Vinate PN Care
205
Voriconazole
55
Vinate Ultra
205
Vorinostat
77
77
Vinblastine Sulfate
81
Votrient
Vincristine Sulfate
81
VP CH Ultra
PAGE 280
52
207
VP-CH Plus
207
Xylocaine-MPF/Epinephrine
168
VP-CH-PNV
207
Xyntha
159
VP-ERA OB Plus
207
Xyntha Solofuse
VP-GGR-B6 Prenatal
207
Xyrem
VP-Heme OB
207
VP-Heme OB + DHA
207
Z
VP-HEME One
207
Zafirlukast
VP-PNV-DHA
207
Zaleplon
166
Vpriv
161
Zanamivir
97
Zanosar
69
159,160
224
30
Vumon
81
Vytorin
56,57
Zatean-CH
208
3,4
Zatean-Pn
208
Zatean-Pn DHA
208
Zatean-Pn Plus
208
Vyvanse
W
Warfarin Sodium
Welchol
33,34
Zelboraf
77
57
Zenpep
137
Westhroid
233
Zetia
59
Westhroid-P
233
Ziagen
94
Wide-Seal Diaphragm 60
170
Ziconotide Acetate
12
170
Zidovudine
170
Zileuton
30
170
Zinacef
110
171
Zingiber
208
171
Zioptan
216
171
Ziprasidone HCl
85
171
Ziprasidone Mesylate
84
Wilate
159
Zoladex
73
WinRho SDF
221
Zoledronic Acid
WP Thyroid
233
Zolinza
Zolmitriptan
X
Xarelto
34
Xeljanz
8
Xenazine
Xenical
226
4
93,94,95
140
77
173,174
Zolpidem Tartrate
166
Zometa
140
Zomig
Zonalon
Zonisamide
173,174
129
39
Xgeva
140
Zorbtive
144
Xiaflex
98
Zortress
99
Xifaxan
23
Zostavax
242
Xolair
29
Zoster Vaccine Live
242
Xopenex HFA
33
Zovia 1/50E (28)
116
Xtandi
73
Zovirax
130
PAGE 281
Zyflo
30
Zyflo CR
30
Zykadia
77
ZyPREXA Relprevv
88
Zytiga
73
Zyvox
25
PAGE 282

Rx Formulary - Millenium Medical Solutions Corp

Transcription

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