Look up a Drug

Transcription

Look up a Drug

Freedom Formulary
(List of Covered Drugs)
2016
for ConnectiCare Plans purchased on Access Health CT (Connecticut Exchange) and most ConnectiCare SOLO plans
This document is the complete ConnectiCare formulary for ConnectiCare plans purchased on Access
Health CT, the state’s insurance exchange. This formulary, also known as a drug list, was last
updated on Sept. 1, 2016. The formulary is subject to change as new drugs come into market or are
removed from the market because the U.S. Food and Drug Administration deems a drug to be unsafe
or if the drug’s manufacturer removes the drug from the market. Please check our website,
www.connecticare.com, for the most up-to-date drug list for your plan.
What is the ConnectiCare formulary?
A formulary is a list of covered drugs selected by ConnectiCare in consultation with a team of health
care providers. It includes the prescription therapies believed to be a necessary part of a quality
treatment program. ConnectiCare will generally cover the drugs listed in our formulary as long as the
drug is medically necessary, the prescription is filled at a ConnectiCare network pharmacy, and other
plan rules are followed.
How do I use the formulary?
To search for your drug within this formulary, please refer to the index, which starts on page 99.
What are generic drugs?
A generic drug is approved by the U.S. Food and Drug Administration (FDA) as having the same
active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
Are there any limitations on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements
and limits may include:
•
•
•
Preauthorization: ConnectiCare requires your physician or you to get preauthorization for
certain drugs. This means that you will need to get approval from ConnectiCare before you fill
your prescriptions. If you don’t get approval, ConnectiCare may not cover the drug.
Quantity limits: For certain drugs, ConnectiCare limits the amount of the drug that we will
cover. For example, ConnectiCare covers Maxalt for 9 tablets per 30 days. This may be in
addition to a standard one-month or three-month supply.
Step therapy: In some cases, ConnectiCare requires you to first try certain drugs to treat your
medical condition before we will cover another drug for that condition. For example, if Drug A
and Drug B both treat your medical condition, ConnectiCare may not cover Drug B unless you
try Drug A first. If Drug A does not work for you, ConnectiCare will then cover Drug B. You can
find out if your drug has any additional requirements or limits by looking in the formulary that
begins on page 4. You can also get more information about the restrictions applied to specific
covered drugs by visiting our website, www.connecticare.com.
Do you speak another language and need assistance?
If you speak a foreign language, translation and interpretation services are available to assist you.
You may obtain interpreter services for verbal communications with us by calling (860) 674-5757 or 1800-251-7722.
Si usted habla un idioma extranjero, la traducción y la interpretación servicios están disponibles para
ayudarle. Usted puede obtener servicios de intérprete para las comunicaciones verbales con
nosotros llamando al (860) 674-5757 o 1-800-251-7722.
Rev. 9.1.2016
Key to abbreviations in the drug list
ACA: Affordable Care Act.
LA: Limited availability. This prescription may be available only at certain pharmacies. For more information,
please call Customer Service.
OTC: Over the counter. An OTC drug is a non-prescription drug.
PA: Preauthorization. The plan requires you or your physician to get prior authorization for certain drugs. This
means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may
not cover the drug.
QL: Quantity limit. For certain drugs, the plan limits the amount of the drug that we will cover.
ST: Step therapy. In some cases, the plan requires you to first try certain drugs to treat your medical condition
before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical
condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then
cover Drug B.
List of Abbreviations
ACA: Affordable Care Act.
LA: Limited Availability. This prescription may be available only at certain pharmacies. For more
information, please call Customer Service.
OTC: Over the Counter. An OTC drug is a non-prescription drug.
PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs.
This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we
may not cover the drug.
QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.
ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical
condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat
your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for
you, we will then cover Drug B.
1
Drug Name
Drug
Tier
Requirements
/ Limits
ANTI - INFECTIVES
ANTIFUNGAL AGENTS
Drug Name
Drug
Tier
Requirements
/ Limits
SPORANOX
PULSEPAK
3
terbinafine hcl
1
VFEND
3
QL
VFEND IV
3
PA
voriconazole
intravenous
1
PA
voriconazole oral
1
QL
PA; QL
ABELCET
3
PA
AMBISOME
3
PA
amphotericin b
1
PA
ANCOBON
3
CANCIDAS
3
clotrimazole
1
CRESEMBA
INTRAVENOUS
3
PA
abacavir
4
CRESEMBA ORAL
3
QL
4
DIFLUCAN
3
abacavirlamivudinezidovudine
ERAXIS(WATER
DILUENT)
3
PA
acyclovir
1
acyclovir sodium
1
fluconazole
1
adefovir
1
fluconazole in
dextrose(iso-o)
1
amantadine hcl
1
flucytosine
1
APTIVUS
4
griseofulvin
microsize
1
ATRIPLA
4
BARACLUDE
3
griseofulvin
ultramicrosize
1
cidofovir
1
COMBIVIR
4
GRIS-PEG
(ULTRAMICROSIZ
E)
3
COMPLERA
4
CRIXIVAN
4
itraconazole
1
CYTOVENE
4
PA; LA
ketoconazole
1
DAKLINZA
4
PA; LA
LAMISIL
3
DESCOVY
4
MYCAMINE
3
didanosine
4
NOXAFIL
3
EDURANT
4
nystatin
1
EMTRIVA
4
ONMEL
3
PA
entecavir
1
ORAVIG
3
ST; QL
EPCLUSA
4
SPORANOX
3
ST; QL
EPIVIR
4
PA
ANTIVIRALS
PA
ST; QL
PA
This Formulary List is subject to change.
2
PA
PA
PA; LA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
EPIVIR HBV
4
REYATAZ
4
EPZICOM
4
rimantadine
1
EVOTAZ
4
SELZENTRY
4
famciclovir
1
SITAVIG
3
PA
FAMVIR
3
SOVALDI
4
PA; LA
FLUMADINE
3
stavudine
4
foscarnet
1
PA
STRIBILD
4
FOSCAVIR
3
PA
SUSTIVA
4
FUZEON
4
PA; LA
SYNAGIS
4
PA; QL
ganciclovir sodium
3
PA; LA
TAMIFLU
2
QL
GENVOYA
4
TECHNIVIE
4
PA; LA
HEPSERA
3
TIVICAY
4
INTELENCE
4
TRIUMEQ
4
INVIRASE
4
TRIZIVIR
4
ISENTRESS
4
TRUVADA
4
KALETRA
4
TYBOST
4
lamivudine
4
TYZEKA
3
lamivudinezidovudine
4
valacyclovir
1
3
LEXIVA
4
VALCYTE ORAL
RECON SOLN
nevirapine
4
3
QL
NORVIR
4
VALCYTE ORAL
TABLET
ODEFSEY
4
valganciclovir
1
QL
OLYSIO
4
VALTREX
3
PREZCOBIX
4
VIDEX 2 GRAM
PEDIATRIC
4
PREZISTA
4
VIDEX EC
4
RAPIVAB
3
PA
VIEKIRA PAK
4
RELENZA
DISKHALER
2
QL
VIRACEPT
4
RESCRIPTOR
4
VIRAMUNE
4
RETROVIR
INTRAVENOUS
4
VIRAMUNE XR
4
VIRAZOLE
3
RETROVIR ORAL
4
VIREAD
4
PA; LA
PA; LA
3
PA; LA; QL
PA
Drug Name
Drug
Tier
VITEKTA
4
ZEPATIER
4
ZERIT
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
cefixime
1
QL
CEFOTAN
3
PA
4
cefotaxime
1
PA
ZIAGEN
4
cefotetan
1
PA
zidovudine
4
3
ZOVIRAX
3
CEFOTETAN IN
DEXTROSE, ISOOSM
cefoxitin
1
PA
1
PA
QL
PA; LA; QL
CEPHALOSPORINS
AVYCAZ
3
PA
CEDAX
3
cefoxitin in dextrose,
iso-osm
cefaclor
1
cefpodoxime
1
cefadroxil
1
cefprozil
1
cefazolin in dextrose
(iso-os) intravenous
piggyback 1 gram/50
ml, 2 gram/50 ml
1
ceftazidime
1
PA
CEFTAZIDIME IN
D5W
3
PA
CEFAZOLIN IN
DEXTROSE (ISOOS)
INTRAVENOUS
PIGGYBACK 2
GRAM/100 ML
3
ceftibuten
1
CEFTIN
3
ceftriaxone in
dextrose,iso-os
1
PA
1
PA
cefazolin injection
recon soln 1 gram,
10 gram, 20 gram,
500 mg
1
ceftriaxone injection
recon soln 1 gram,
10 gram, 2 gram,
250 mg, 500 mg
3
PA
cefazolin injection
recon soln 100
gram, 300 g
1
CEFTRIAXONE
INJECTION
RECON SOLN 100
GRAM
cefazolin
intravenous
1
ceftriaxone
intravenous
1
PA
cefdinir
1
cefuroxime axetil
1
cefditoren pivoxil
1
cefuroxime sodium
1
cefepime
1
cephalexin
1
CEFEPIME IN
DEXTROSE 5 %
3
FORTAZ
3
PA
3
PA
cefepime in
dextrose,iso-osm
1
FORTAZ IN
DEXTROSE 5 %
KEFLEX
3
PA
PA
PA
PA
PA
PA
4
PA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
MAXIPIME
3
PA
erythromycin
1
MEFOXIN IN
DEXTROSE (ISOOSM)
3
PA
erythromycin
ethylsuccinate
1
PCE
3
SPECTRACEF
3
3
QL
ZITHROMAX
INTRAVENOUS
3
SUPRAX
TAZICEF
3
PA
3
TEFLARO
3
PA
ZITHROMAX
ORAL
ZERBAXA
3
PA
ZMAX
3
ZINACEF
3
PA
MISCELLANEOUS ANTIINFECTIVES
ZINACEF IN
STERILE WATER
3
PA
ALBENZA
3
ALINIA
3
QL
ERYTHROMYCINS & OTHER
MACROLIDES
amikacin
1
PA
atovaquone
1
PA
azithromycin
intravenous
1
atovaquoneproguanil
1
PA
azithromycin oral
1
AZACTAM
3
PA
BIAXIN
3
3
PA
clarithromycin
1
DIFICID
3
AZACTAM IN
DEXTROSE (ISOOSM)
e.e.s. 400
1
aztreonam
1
PA
E.E.S. GRANULES
3
baciim
1
PA
ERYPED 200
2
bacitracin
1
PA
ERYPED 400
2
BETHKIS
4
ery-tab oral
tablet,delayed
release (dr/ec) 250
mg, 333 mg
1
BILTRICIDE
3
CAPASTAT
3
PA
CAYSTON
4
PA
ERY-TAB ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 500 MG
2
chloramphenicol sod
succinate
1
PA
chloroquine
phosphate
1
PA
ERYTHROCIN
3
3
PA
erythrocin (as
stearate)
1
CLEOCIN IN 5 %
DEXTROSE
CLEOCIN
INJECTION
3
PA
PA
PA; QL
PA
5
Requirements
/ Limits
PA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
PA
GENTAMICIN IN
NACL (ISO-OSM)
INTRAVENOUS
PIGGYBACK 100
MG/50 ML, 120
MG/100 ML
3
PA
gentamicin sulfate
(ped) (pf)
1
PA
gentamicin sulfate
(pf) intravenous
solution 100 mg/10
ml
1
PA
GENTAMICIN
SULFATE (PF)
INTRAVENOUS
SOLUTION 60
MG/6 ML
3
PA
hydroxychloroquine
1
imipenem-cilastatin
1
PA
IMPAVIDO
3
PA
INVANZ
3
PA
isoniazid injection
1
PA
isoniazid oral
1
CLEOCIN
INTRAVENOUS
3
CLEOCIN ORAL
3
CLIN SINGLE USE
3
clindamycin hcl
1
clindamycin in 5 %
dextrose
1
clindamycin
palmitate hcl
1
clindamycin
pediatric
1
clindamycin
phosphate
1
PA
COARTEM
3
PA
colistin
(colistimethate na)
1
PA
COLY-MYCIN M
PARENTERAL
3
PA
CYCLOSERINE
3
DALVANCE
3
dapsone
1
DARAPRIM
4
PA
ivermectin
1
DORIBAX
3
PA
KETEK
3
EMVERM
3
KITABIS PAK
4
ethambutol
1
linezolid intravenous
1
PA
FLAGYL
3
linezolid oral
1
QL
FLAGYL ER
3
1
PA
gentamicin
1
PA
linezolid-0.9%
sodium chloride
gentamicin in nacl
(iso-osm)
intravenous
piggyback 100
mg/100 ml, 60 mg/50
ml, 70 mg/50 ml, 80
mg/100 ml, 80 mg/50
ml, 90 mg/100 ml
1
PA
MALARONE
3
PA
MALARONE
PEDIATRIC
3
PA
mefloquine
1
PA
MEPRON
3
PA
meropenem
1
PA
PA
PA
PA
6
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
MERREM
3
PA
STREPTOMYCIN
3
metro i.v.
1
PA
STROMECTOL
3
metronidazole
1
TINDAMAX
3
QL
metronidazole in
nacl (iso-os)
1
tinidazole
1
QL
TOBI
4
PA
MYAMBUTOL
3
TOBI PODHALER
4
MYCOBUTIN
3
4
PA
NEBUPENT
3
tobramycin in 0.225
% nacl
neomycin
1
1
PA
ORBACTIV
3
tobramycin in 0.9 %
nacl
paromomycin
1
tobramycin sulfate
1
PA
PASER
3
TRECATOR
3
PENTAM
3
TYGACIL
3
PLAQUENIL
3
XIFAXAN
3
polymyxin b sulfate
1
ZYVOX
INTRAVENOUS
3
PA
PRIFTIN
2
ZYVOX ORAL
3
QL
PRIMAQUINE
2
PRIMAXIN IV
3
pyrazinamide
1
QUALAQUIN
3
quinine sulfate
1
rifabutin
1
RIFADIN
INTRAVENOUS
3
RIFADIN ORAL
3
RIFAMATE
3
rifampin intravenous
1
rifampin oral
1
RIFATER
3
SIRTURO
3
SIVEXTRO
INTRAVENOUS
3
SIVEXTRO ORAL
3
PA
PA
PA
PA
PA
PA
PENICILLINS
PA
PA
PA
PA
PA
amoxicillin oral
capsule
1
amoxicillin oral
suspension for
reconstitution
1
amoxicillin oral
tablet
1
AMOXICILLIN
ORAL TABLET,
ER MULTIPHASE
24 HR
3
amoxicillin oral
tablet,chewable
1
amoxicillin-pot
clavulanate
1
ampicillin
1
ampicillin sodium
1
7
PA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
PA
pfizerpen-g
1
PA
ampicillin-sulbactam
1
AUGMENTIN ES600
3
piperacillintazobactam
1
PA
AUGMENTIN
ORAL
SUSPENSION FOR
RECONSTITUTIO
N 125-31.25 MG/5
ML
2
UNASYN
3
PA
ZOSYN
3
PA
ZOSYN IN
DEXTROSE (ISOOSM)
3
PA
AUGMENTIN
ORAL
SUSPENSION FOR
RECONSTITUTIO
N 250-62.5 MG/5
ML
3
AUGMENTIN
ORAL TABLET
3
AUGMENTIN XR
3
BICILLIN C-R
3
PA
BICILLIN L-A
3
PA
dicloxacillin
1
MOXATAG
3
nafcillin
1
nafcillin in dextrose
iso-osm
QUINOLONES
AVELOX
3
AVELOX ABC
PACK
2
AVELOX IN NACL
(ISO-OSMOTIC)
3
CIPRO
3
CIPRO IN D5W
3
CIPRO XR
3
ciprofloxacin
1
ciprofloxacin
(mixture)
1
PA
ciprofloxacin hcl
1
1
PA
ciprofloxacin in 5 %
dextrose
1
PA
oxacillin
1
PA
ciprofloxacin lactate
1
PA
oxacillin in
dextrose(iso-osm)
1
PA
FACTIVE
3
LEVAQUIN
3
PENICILLIN G
POT IN
DEXTROSE
3
PA
levofloxacin in d5w
1
PA
1
PA
penicillin g
potassium
1
levofloxacin
intravenous
levofloxacin oral
1
penicillin g procaine
1
PA
moxifloxacin
1
penicillin g sodium
1
PA
3
penicillin v
potassium
1
MOXIFLOXACINSOD.ACE,SULWATER
ofloxacin
1
PA
8
PA
PA
PA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
SULFA'S & RELATED AGENTS
MINOCIN ORAL
3
BACTRIM
3
1
BACTRIM DS
3
minocycline oral
capsule
sulfadiazine
1
minocycline oral
tablet
1
sulfamethoxazoletrimethoprim
intravenous
1
minocycline oral
tablet extended
release 24 hr
1
sulfamethoxazoletrimethoprim oral
1
mondoxyne nl
1
sulfatrim
1
MONODOX
3
morgidox
1
MORGIDOX 2X100
3
ORACEA
3
ST
SOLODYN
3
ST
tetracycline
1
VIBRAMYCIN
ORAL CAPSULE
3
VIBRAMYCIN
ORAL
SUSPENSION FOR
RECONSTITUTIO
N
3
VIBRAMYCIN
ORAL SYRUP
2
PA
TETRACYCLINES
ACTICLATE
3
PA
avidoxy
1
AVIDOXY DK
3
demeclocycline
1
DORYX
3
ST
DORYX MPC
3
PA
doxy-100
1
PA
doxycycline hyclate
1
doxycycline
monohydrate oral
capsule
1
DOXYCYCLINE
MONOHYDRATE
ORAL
CAPSULE,IR DELAY
REL,BIPHASE
3
doxycycline
monohydrate oral
suspension for
reconstitution
1
doxycycline
monohydrate oral
tablet
1
MINOCIN
INTRAVENOUS
3
PA
ST
PA
ST
ST
ST
URINARY TRACT AGENTS
FURADANTIN
3
HIPREX
3
MACROBID
3
MACRODANTIN
3
methenamine
hippurate
1
methenamine
mandelate
1
MONUROL
3
nitrofurantoin
1
9
QL
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
nitrofurantoin
macrocrystal
1
ZINECARD (AS
HCL)
nitrofurantoin
monohyd/m-cryst
1
ANTINEOPLASTIC &
IMMUNOSUPPRESSANT DRUGS
PRIMSOL
3
ABRAXANE
4
PA; LA
trimethoprim
1
ADCETRIS
4
PA
adrucil
4
PA; LA
AFINITOR
4
PA; LA
VANCOMYCIN
4
Requirements
/ Limits
PA; LA
VANCOCIN
3
VANCOMYCIN IN
DEXTROSE 5 %
3
PA
AFINITOR
DISPERZ
4
PA; LA
vancomycin
intravenous
1
PA
ALECENSA
4
PA; LA
ALIMTA
4
PA; LA
vancomycin oral
1
4
PA; LA
VIBATIV
3
ALKERAN
INTRAVENOUS
ANTINEOPLASTIC &
IMMUNOSUPPRESSANT DRUGS
ALKERAN ORAL
2
anastrozole
1
ADJUNCTIVE AGENTS
ARIMIDEX
3
AROMASIN
3
ARRANON
4
PA; LA
ARZERRA
4
PA; LA
ASTAGRAF XL
4
AVASTIN
4
PA; LA
azacitidine
4
PA; LA
AZASAN
4
azathioprine
4
PA
amifostine
crystalline
4
PA; LA
dexrazoxane hcl
4
PA; LA
ELITEK
4
PA; LA
KEPIVANCE
4
PA; LA
leucovorin calcium
injection
4
PA; LA
leucovorin calcium
oral
1
mesna
4
PA; LA
azathioprine sodium
1
PA
MESNEX
INTRAVENOUS
4
PA; LA
BELEODAQ
4
PA
BENDEKA
4
PA; LA
MESNEX ORAL
3
bexarotene
1
PA
VISTOGARD
4
PA
bicalutamide
1
VORAXAZE
3
PA
BICNU
4
PA; LA
XGEVA
4
QL
bleomycin
4
PA; LA
BLINCYTO
4
PA
10
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
BOSULIF
4
PA; LA; QL
DARZALEX
4
PA; LA
BUSULFEX
4
PA; LA
daunorubicin
4
PA; LA
CABOMETYX
4
PA; LA; QL
decitabine
4
PA; LA
CAMPATH
3
PA
DOCEFREZ
4
PA; LA
CAMPTOSAR
4
PA; LA
docetaxel
4
PA; LA
capecitabine
4
PA; LA
DOXIL
4
PA; LA
CAPRELSA
4
PA; QL
doxorubicin
4
PA; LA
carboplatin
4
PA; LA
1
PA
CASODEX
3
doxorubicin, pegliposomal
CELLCEPT
INTRAVENOUS
4
DROXIA
2
ELIGARD
4
LA
CELLCEPT ORAL
CAPSULE
4
ELLENCE
4
PA; LA
EMCYT
3
CELLCEPT ORAL
SUSPENSION FOR
RECONSTITUTIO
N
4
EMPLICITI
4
ENVARSUS XR
4
epirubicin
4
PA; LA
cisplatin
4
PA; LA
ERBITUX
4
PA; LA
cladribine
4
PA; LA
ERIVEDGE
4
PA; LA; QL
CLOLAR
4
PA; LA
ERWINAZE
4
PA; LA
COMETRIQ
4
PA; QL
ETOPOPHOS
4
PA; LA
COSMEGEN
4
PA; LA
PA; LA
4
PA; LA
etoposide
intravenous
4
COTELLIC
cyclophosphamide
4
PA; LA
etoposide oral
1
cyclosporine
intravenous
4
PA; LA
EVOMELA
4
exemestane
1
cyclosporine
modified
4
FARESTON
2
cyclosporine oral
4
FARYDAK
4
PA; LA
CYRAMZA
4
PA
FASLODEX
4
PA
cytarabine
4
PA; LA
FEMARA
3
cytarabine (pf)
4
PA; LA
4
PA
dacarbazine
4
PA; LA
FIRMAGON KIT W
DILUENT
SYRINGE
DACOGEN
4
PA; LA
floxuridine
4
PA; LA
PA; LA
PA
11
PA; LA
PA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
fludarabine
4
PA; LA
irinotecan
4
PA; LA
fluorouracil
4
PA; LA
ISTODAX
4
PA; LA
flutamide
1
IXEMPRA
4
PA; LA
FOLOTYN
4
PA; LA
JAKAFI
4
PA; LA; QL
GAZYVA
4
PA; LA
JEVTANA
4
PA; LA
gemcitabine
4
PA; LA
KADCYLA
4
PA; LA
GEMZAR
4
PA; LA
KEYTRUDA
4
PA
gengraf
4
KYPROLIS
4
PA; LA
GILOTRIF
4
PA; LA; QL
LENVIMA
4
PA; LA
GLEEVEC
4
PA; LA
letrozole
1
GLEOSTINE
3
LEUKERAN
2
GLIADEL WAFER
3
leuprolide
4
HALAVEN
4
PA; LA
lipodox
4
PA; LA
HERCEPTIN
4
PA; LA
LONSURF
4
PA; LA
HEXALEN
3
LUPRON DEPOT
4
HYCAMTIN
4
4
HYDREA
3
LUPRON DEPOT
(3 MONTH)
hydroxyurea
1
LUPRON DEPOT
(4 MONTH)
4
IBRANCE
4
PA; LA; QL
4
PA; QL
LUPRON DEPOT
(6 MONTH)
4
ICLUSIG
IDAMYCIN PFS
4
PA; LA
4
idarubicin
4
PA; LA
LUPRON DEPOTPED
IFEX
4
PA; LA
LUPRON DEPOTPED (3 MONTH)
4
ifosfamide
4
PA; LA
LYNPARZA
4
ifosfamide-mesna
4
PA; LA
LYSODREN
3
imatinib
4
PA; LA
MARQIBO
4
IMBRUVICA
4
PA; QL
MATULANE
4
IMLYGIC
4
PA; LA
MEGACE
3
IMURAN
4
MEGACE ES
3
INLYTA
4
PA; LA; QL
megestrol
1
IODOPEN
3
PA
MEKINIST
4
IRESSA
4
PA
PA; LA
12
Drug
Tier
Requirements
/ Limits
PA
PA
PA; LA; QL
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
PA; LA
PURIXAN
4
Requirements
/ Limits
melphalan hcl
4
mercaptopurine
1
RAPAMUNE
4
methotrexate sodium
(pf)
4
RHEUMATREX
3
RITUXAN
4
PA; LA
methotrexate sodium
injection
4
SANDIMMUNE
INTRAVENOUS
4
PA
methotrexate sodium
oral
1
SANDIMMUNE
ORAL
4
mitomycin
4
PA; LA
SANDOSTATIN
4
PA
mitoxantrone
4
PA; LA
4
PA; QL
MUSTARGEN
4
PA; LA
mycophenolate
mofetil
4
SANDOSTATIN
LAR DEPOT
INTRAMUSCULA
R KIT
mycophenolate
sodium
4
4
PA; LA; QL
MYFORTIC
4
MYLERAN
2
NAVELBINE
4
SANDOSTATIN
LAR DEPOT
INTRAMUSCULA
R
SUSPENSION,EXT
ENDED REL
RECON
NEORAL
4
SIGNIFOR
4
PA; LA
NEXAVAR
4
SIGNIFOR LAR
4
PA; LA; QL
NILANDRON
2
SIMULECT
4
PA; LA
NINLARO
4
PA; LA
sirolimus
4
NIPENT
4
PA; LA
SOLTAMOX
0
ACA
NULOJIX
4
PA; LA
4
PA
octreotide acetate
4
PA
SOMATULINE
DEPOT
ODOMZO
4
PA; LA; QL
SPRYCEL
4
PA; LA
OPDIVO
4
PA
STIVARGA
4
PA; LA; QL
oxaliplatin
4
PA; LA
SUTENT
4
PA; LA; QL
paclitaxel
4
PA; LA
SYLVANT
4
PA; LA
PERJETA
4
PA; LA
SYNRIBO
4
PA
PHOTOFRIN
4
PA; LA
TABLOID
3
PROGRAF
INTRAVENOUS
4
PA; LA
tacrolimus
4
TAFINLAR
4
PROGRAF ORAL
4
PA; LA
PA; LA
13
PA; LA; QL
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
TAGRISSO
4
PA; LA
vincasar pfs
4
PA; LA
tamoxifen
0
ACA
vincristine
4
PA; LA
TARCEVA
4
PA; LA; QL
vinorelbine
4
PA; LA
TARGRETIN
ORAL
3
PA
VOTRIENT
4
PA; LA
XALKORI
4
PA; LA; QL
TARGRETIN
TOPICAL
2
XELODA
4
PA; LA
TASIGNA
4
PA; LA
XTANDI
4
PA; LA; QL
TAXOTERE
4
PA; LA
YERVOY
4
PA; LA
TECENTRIQ
4
PA; LA
YONDELIS
4
PA; LA
TEMODAR
4
PA; LA
ZALTRAP
4
PA; LA
temozolomide
4
PA; LA
ZANOSAR
4
PA; LA
TENIPOSIDE
3
PA
ZELBORAF
4
PA; LA
THALOMID
4
PA; LA; QL
ZEVALIN (Y-90)
4
PA; LA
thiotepa
4
PA; LA
ZOLADEX
4
PA; LA
toposar
4
PA; LA
ZOLINZA
4
PA; LA
topotecan
4
PA; LA
ZORTRESS
4
PA; LA
TORISEL
4
PA; LA
ZYDELIG
4
PA
TREANDA
4
PA; LA
ZYKADIA
4
PA; LA
TRELSTAR
4
PA
ZYTIGA
4
PA; LA; QL
tretinoin
(chemotherapy)
1
AUTONOMIC & CNS DRUGS,
NEUROLOGY & PSYCH
TREXALL
3
ANTICONVULSANTS
TRISENOX
4
PA; LA
APTIOM
3
TYKERB
4
PA; LA; QL
BANZEL
3
UNITUXIN
4
PA; LA
3
VECTIBIX
4
PA; LA
BRIVIACT
INTRAVENOUS
VELCADE
4
PA; LA
BRIVIACT ORAL
3
VENCLEXTA
4
PA; LA
carbamazepine
1
VENCLEXTA
STARTING PACK
4
PA; LA
CARBATROL
3
CELONTIN
2
VIDAZA
4
PA; LA
CEREBYX
3
vinblastine
4
PA; LA
clonazepam
1
14
Requirements
/ Limits
PA
PA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
DEPACON
3
DEPAKENE
3
DEPAKOTE
3
DEPAKOTE ER
3
DEPAKOTE
SPRINKLES
3
DIASTAT
PA
KEPPRA
INTRAVENOUS
3
KEPPRA ORAL
3
KEPPRA XR
3
KLONOPIN
3
LAMICTAL
3
3
LAMICTAL ODT
3
DIASTAT
ACUDIAL
3
LAMICTAL ODT
STARTER (BLUE)
3
diazepam
1
3
DILANTIN
2
LAMICTAL ODT
STARTER
(GREEN)
DILANTIN
EXTENDED
3
3
DILANTIN
INFATABS
3
LAMICTAL ODT
STARTER
(ORANGE)
PA
3
divalproex
1
LAMICTAL
STARTER (BLUE)
KIT
3
DILANTIN-125
epitol
1
3
PA
EQUETRO
3
LAMICTAL
STARTER
(GREEN) KIT
ethosuximide
1
3
PA
felbamate
1
LAMICTAL
STARTER
(ORANGE) KIT
FELBATOL
3
LAMICTAL XR
3
PA
fosphenytoin
1
PA
3
LAMICTAL XR
STARTER (BLUE)
3
FYCOMPA
gabapentin
1
3
PA
GABITRIL ORAL
TABLET 12 MG, 16
MG
2
LAMICTAL XR
STARTER
(GREEN)
3
PA
GABITRIL ORAL
TABLET 2 MG, 4
MG
3
LAMICTAL XR
STARTER
(ORANGE)
1
GRALISE
3
PA
lamotrigine oral
tablet
GRALISE 30-DAY
STARTER PACK
3
PA
lamotrigine oral
tablet disintegrating,
dose pk
1
PA
15
Drug
Tier
Requirements
/ Limits
PA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
PA
tiagabine
1
TOPAMAX
3
Requirements
/ Limits
lamotrigine oral
tablet extended
release 24hr
1
lamotrigine oral
tablet, chewable
dispersible
1
topiramate oral
capsule, sprinkle
1
3
lamotrigine oral
tablet,disintegrating
1
TOPIRAMATE
ORAL
CAPSULE,SPRINK
LE,ER 24HR
LEVETIRACETAM
IN NACL (ISO-OS)
3
topiramate oral
tablet
1
levetiracetam
intravenous
1
TRILEPTAL
3
levetiracetam oral
1
TROKENDI XR
3
PA
LYRICA
3
valproate sodium
1
PA
MYSOLINE
3
valproic acid
1
NEURONTIN
3
valproic acid (as
sodium salt)
1
ONFI
3
3
oxcarbazepine
1
VIMPAT
INTRAVENOUS
OXTELLAR XR
3
VIMPAT ORAL
3
PEGANONE
3
ZARONTIN
3
phenobarbital
1
ZONEGRAN
3
PHENYTEK
3
zonisamide
1
phenytoin
1
ANTIPARKINSONISM AGENTS
phenytoin sodium
1
phenytoin sodium
extended
1
POTIGA
3
primidone
1
QUDEXY XR
3
roweepra
1
SABRIL
4
SPRITAM
PA
PA
PA
PA
APOKYN
4
AZILECT
2
benztropine injection
1
benztropine oral
1
bromocriptine
1
carbidopa
1
carbidopa-levodopa
1
carbidopa-levodopaentacapone
1
3
TEGRETOL
3
COGENTIN
3
TEGRETOL XR
3
COMTAN
3
PA
16
PA
PA; LA; QL
PA
PA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
DUOPA
4
TASMAR
3
ELDEPRYL
3
tolcapone
1
entacapone
1
trihexyphenidyl
1
LODOSYN
3
ZELAPAR
3
MIRAPEX
3
MIRAPEX ER
3
MIGRAINE & CLUSTER HEADACHE
THERAPY
NEUPRO
3
almotriptan malate
1
QL
PARLODEL
3
ALSUMA
3
PA; QL
pramipexole
1
AMERGE
3
QL
REQUIP ORAL
TABLET 0.25 MG,
0.5 MG, 1 MG, 2
MG
3
AXERT
3
PA; QL
CAFERGOT
3
D.H.E.45
3
PA
REQUIP ORAL
TABLET 3 MG, 4
MG, 5 MG
3
dihydroergotamine
injection
1
PA
1
QL
REQUIP XL
3
dihydroergotamine
nasal
ropinirole oral tablet
0.25 mg, 0.5 mg, 1
mg, 2 mg
1
ERGOMAR
3
FROVA
3
QL
frovatriptan
1
QL
3 mg, 4 mg, 5 mg
1
IMITREX
3
QL
extended release 24
hr
1
IMITREX
STATDOSE KIT
REFILL
3
QL
RYTARY
3
IMITREX
STATDOSE PEN
3
QL
selegiline hcl
1
3
isometh-dichloralacetaminophn
1
SINEMET
SINEMET CR
3
1
STALEVO 100
3
isomethepten-cafacetaminophen
STALEVO 125
3
MAXALT
3
QL
STALEVO 150
3
MAXALT-MLT
3
QL
STALEVO 200
3
migergot
1
STALEVO 50
3
MIGRANAL
3
QL
STALEVO 75
3
naratriptan
1
QL
QL
ST
QL
17
Drug Name
Drug
Tier
nodolor
1
PRODRIN
3
RELPAX
3
rizatriptan
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
3
PA
PA; QL
MEMANTINE
ORAL
TABLETS,DOSE
PACK
1
QL
NAMENDA
3
PA
sumatriptan
1
QL
3
PA
sumatriptan
succinate
1
QL
NAMENDA
TITRATION PAK
NAMENDA XR
3
PA
SUMAVEL
DOSEPRO
3
PA
NAMZARIC
3
PA
NUEDEXTA
3
PA; QL
TREXIMET
3
PA; QL
RAZADYNE
3
PA
zolmitriptan
1
QL
RAZADYNE ER
3
PA
ZOMIG
2
QL
rivastigmine
1
PA
ZOMIG ZMT
3
QL
rivastigmine tartrate
1
PA
tetrabenazine
4
PA; LA; QL
TYSABRI
4
PA; LA
XENAZINE
4
PA; LA
MISCELLANEOUS NEUROLOGICAL
THERAPY
AMPYRA
4
PA; LA; QL
ARICEPT ORAL
TABLET 10 MG, 5
MG
3
ARICEPT ORAL
TABLET 23 MG
3
donepezil oral tablet
10 mg, 5 mg
1
donepezil oral tablet
23 mg
1
PA
donepezil oral
1
PA
EXELON
3
galantamine
MUSCLE RELAXANTS &
ANTISPASMODIC THERAPY
PA
AMRIX
3
baclofen
1
carisoprodol
1
carisoprodol-asacodeine
1
carisoprodol-aspirin
1
chlorzoxazone
1
PA
cyclobenzaprine
1
1
PA
3
HORIZANT
3
ST; QL
DANTRIUM
INTRAVENOUS
KEVEYIS
4
PA; QL
DANTRIUM ORAL
3
memantine oral
solution
1
PA
dantrolene
1
FEXMID
3
memantine oral
tablet
1
LORZONE
3
meprobamate
1
PA
18
ST; QL
PA
ST
Drug Name
Drug
Tier
MESTINON
Requirements
/ Limits
Drug Name
Drug
Tier
3
ALLZITAL
3
MESTINON
TIMESPAN
3
ascomp with codeine
1
ASTRAMORPH-PF
3
PA
metaxall
1
BELBUCA
3
PA; QL
metaxalone
1
BUPAP
3
methocarbamol
injection
1
BUPRENEX
3
PA
methocarbamol oral
1
buprenorphine hcl
injection
1
PA
orphenadrine citrate
injection
1
buprenorphine hcl
sublingual
1
orphenadrine citrate
oral
1
butalbital compound
w/codeine
1
PARAFON FORTE
DSC
3
butalbitalacetaminop-caf-cod
1
pyridostigmine
bromide
1
butalbitalacetaminophen
1
regonol
1
PA
1
PA
butalbitalacetaminophen-caff
1
revonto
ROBAXIN
INJECTION
2
PA
butalbital-aspirincaffeine
1
ROBAXIN ORAL
3
BUTRANS
2
ROBAXIN-750
3
capacet
1
RYANODEX
3
2
SKELAXIN
3
CAPITAL WITH
CODEINE
SOMA ORAL
TABLET 250 MG
3
codeine sulfate
1
1
SOMA ORAL
TABLET 350 MG
3
codeine-butalbitalasa-caff
3
PA
tizanidine
1
ZANAFLEX
3
DEMEROL (PF)
INJECTION
SOLUTION 100
MG/2 ML, 25
MG/0.5 ML, 75
MG/1.5 ML
demerol (pf)
injection solution
100 mg/ml
1
PA
PA
PA
PA
PA
NARCOTIC ANALGESICS
ABSTRAL
3
acetaminophencodeine
1
ACTIQ
3
PA; QL
PA; QL
19
Requirements
/ Limits
QL
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
PA
FIORICET WITH
CODEINE
3
FIORINAL
3
FIORINALCODEINE #3
3
HYCET
3
hydrocodoneacetaminophen
1
hydrocodoneibuprofen
1
hydromorphone (pf)
1
PA
hydromorphone
injection solution
1
PA
HYDROMORPHO
NE INJECTION
SYRINGE 0.5
MG/0.5 ML
3
PA
hydromorphone
injection syringe 1
mg/ml, 2 mg/ml, 4
mg/ml
1
PA
hydromorphone oral
liquid
1
hydromorphone oral
tablet
1
hydromorphone oral
tablet extended
release 24 hr
1
hydromorphone
rectal
1
HYSINGLA ER
3
IBUDONE
3
ibuprofen-oxycodone
1
QL
INFUMORPH P/F
3
PA
KADIAN
3
LAZANDA
3
levorphanol tartrate
1
DEMEROL (PF)
INJECTION
SYRINGE
3
DEMEROL
INJECTION
3
DEMEROL ORAL
3
dihydrocodeacetaminophen-caff
1
dihydrocodeineaspirin-caff
1
DILAUDID
3
DILAUDID-HP
(PF)
3
diskets
1
DOLOPHINE
3
DURAGESIC
3
duramorph (pf)
1
PA
EMBEDA
3
PA
endocet
1
ESGIC
3
EXALGO ER
3
QL
fentanyl citrate
1
PA; QL
fentanyl citrate (pf)
1
PA
fentanyl transdermal
patch 72 hour 100
mcg/hr, 12 mcg/hr,
25 mcg/hr, 50
mcg/hr, 75 mcg/hr
1
FENTANYL
TRANSDERMAL
PATCH 72 HOUR
37.5 MCG/HOUR,
62.5 MCG/HOUR,
87.5 MCG/HOUR
3
FENTORA
3
FIORICET
3
PA
PA
PA; QL
20
Drug
Tier
Requirements
/ Limits
QL
PA
PA; QL
Drug Name
Drug
Tier
Requirements
/ Limits
lorcet (hydrocodone)
1
lorcet hd
1
lorcet plus
1
lortab 10-325
1
lortab 5-325
1
lortab 7.5-325
1
LORTAB ELIXIR
3
margesic
1
marten-tab
1
meperidine (pf)
1
PA
meperidine injection
1
PA
meperidine oral
1
methadone injection
1
methadone oral
1
methadose
1
morphine (pf)
1
morphine
concentrate
1
morphine injection
1
MORPHINE
INTRAMUSCULA
R
3
morphine
intravenous
1
morphine oral
1
morphine rectal
Drug Name
Drug
Tier
oxycodone oral
concentrate
1
oxycodone oral
solution
1
oxycodone oral
tablet
1
OXYCODONE
ORAL
TABLET,ORAL
ONLY,EXT.REL.12
HR
3
oxycodoneacetaminophen
1
oxycodone-aspirin
1
OXYCONTIN
3
oxymorphone
1
PERCOCET
3
PRIMLEV
3
reprexain
1
ROXICODONE
3
SUBSYS
3
SYNALGOS-DC
3
tencon
1
TREZIX
3
TYLENOLCODEINE #3
3
TYLENOLCODEINE #4
3
1
MS CONTIN
3
VANATOL LQ
3
NORCO
3
verdrocet
1
OPANA
3
vicodin
1
OPANA ER
3
PA
vicodin es
1
OXAYDO
3
PA
vicodin hp
1
oxycodone oral
capsule
1
XARTEMIS XR
3
XODOL 10/300
3
PA
PA
PA
PA
21
Requirements
/ Limits
PA; QL
PA; QL
PA; QL
PA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
XODOL 5/300
3
diflunisal
1
XODOL 7.5/300
3
DISALCID
3
xylon 10
1
DUEXIS
3
PA; QL
zamicet
1
DYLOJECT
3
PA
zebutal
1
EC-NAPROSYN
3
ZOHYDRO ER
3
etodolac
1
NON-NARCOTIC ANALGESICS
EVZIO
4
ANAPROX DS
3
FELDENE
3
ARTHROTEC 50
3
PA
fenoprofen
1
ARTHROTEC 75
3
PA
FLECTOR
3
BUNAVAIL
3
PA; QL
flurbiprofen
1
buprenorphinenaloxone
1
PA
ibuprofen
1
INDOCIN ORAL
2
butorphanol tartrate
injection
1
PA
INDOCIN RECTAL
3
butorphanol tartrate
nasal
1
QL
indomethacin
1
ketoprofen
1
CALDOLOR
3
PA
ketorolac
1
QL
CAMBIA
3
PA; QL
klofensaid ii
1
PA; QL
CELEBREX
3
QL
meclofenamate
1
celecoxib
1
QL
mefenamic acid
1
choline,magnesium
salicylate
1
meloxicam
1
MOBIC
3
CONZIP
3
nabumetone
1
DAYPRO
3
nalbuphine
1
diclofenac potassium
1
naloxone
1
diclofenac sodium
oral
1
naltrexone
1
diclofenac sodium
topical drops
1
NAPRELAN CR
3
NAPROSYN
3
diclofenac sodium
topical gel
1
naproxen
1
naproxen sodium
1
diclofenacmisoprostol
1
NARCAN
3
NUCYNTA
3
PA; QL
PA
PA; QL
22
QL
PA
PA
QL
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
NUCYNTA ER
2
ZIPSOR
3
PA
oxaprozin
1
ZORVOLEX
3
PA
PENNSAID
3
ZUBSOLV
3
PA
pentazocinenaloxone
1
piroxicam
1
PONSTEL
PA
PSYCHOTHERAPEUTIC DRUGS
ABILIFY
3
QL
ABILIFY
MAINTENA
3
PA; QL
3
REVIA
3
ADASUVE
3
salsalate
1
ADDERALL
3
SPRIX
4
ST; QL
ADDERALL XR
3
SUBOXONE
2
QL
3
sulindac
1
ADZENYS XRODT
TALWIN
3
PA
alprazolam
1
TIVORBEX
3
PA
alprazolam intensol
1
tolmetin
1
AMBIEN
3
TRAMADOL
ORAL
CAPSULE,ER
BIPHASE 24 HR
25-75
3
AMBIEN CR
3
amitriptyline
1
amitriptylinechlordiazepoxide
1
tramadol oral tablet
1
amoxapine
1
tramadol oral tablet
extended release 24
hr
1
ANAFRANIL
3
APLENZIN
3
APTENSIO XR
3
tramadol oral tablet,
er multiphase 24 hr
1
aripiprazole oral
solution
1
tramadolacetaminophen
1
aripiprazole oral
tablet
1
QL
ULTRACET
3
QL
3
aripiprazole oral
1
ULTRAM
ULTRAM ER
3
ARISTADA
3
QL
VIMOVO
3
PA
armodafinil
1
PA; QL
VIVITROL
4
LA; QL
ATIVAN
3
VOLTAREN
3
BELSOMRA
3
VOLTAREN-XR
3
BRISDELLE
3
PA
23
PA
PA; QL
Drug Name
Drug
Tier
bupropion hcl
1
buspirone
1
BUTISOL
3
CELEXA
3
chlordiazepoxide hcl
1
chlorpromazine
injection
1
chlorpromazine oral
1
citalopram
1
clomipramine
1
clonidine hcl
1
clorazepate
dipotassium
1
clozapine oral tablet
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
DEXEDRINE
SPANSULE
3
dexmethylphenidate
1
dextroamphetamine
1
dextroamphetamineamphetamine
1
diazepam injection
1
diazepam intensol
1
diazepam oral
1
DORAL
3
doxepin
1
duloxetine
1
DYANAVEL XR
3
1
EDLUAR
3
clozapine oral
100 mg, 12.5 mg, 25
mg
1
EFFEXOR XR
3
EMSAM
3
ergoloid
1
CLOZAPINE
ORAL
TABLET,DISINTE
GRATING 150 MG,
200 MG
3
escitalopram oxalate
1
estazolam
1
eszopiclone
1
EVEKEO
3
CLOZARIL
3
FANAPT
3
CONCERTA
3
FAZACLO
3
CYMBALTA
3
FETZIMA
3
PA
DAYTRANA
3
flumazenil
1
PA
desipramine
1
1
DESOXYN
3
fluoxetine oral
capsule
DESVENLAFAXIN
E
3
1
DESVENLAFAXIN
E FUMARATE
3
fluoxetine oral
capsule,delayed
release(dr/ec)
1
dexedrine
1
fluoxetine oral
solution
fluoxetine oral tablet
10 mg, 20 mg
1
PA
PA
24
PA
PA
QL
ST; QL
QL
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
PA
INVEGA
3
QL
INVEGA
SUSTENNA
3
ST; QL
INVEGA TRINZA
3
ST
IRENKA
3
PA
KAPVAY
3
FLUOXETINE
ORAL TABLET 60
MG
3
fluphenazine
decanoate
1
PA
fluphenazine hcl
injection
1
PA
fluphenazine hcl oral
1
KHEDEZLA
3
PA
flurazepam
1
LATUDA
3
ST; QL
fluvoxamine
1
LEXAPRO
3
FOCALIN
3
lithium carbonate
1
FOCALIN XR
3
lithium citrate
1
FORFIVO XL
3
PA
LITHOBID
3
GEODON
INTRAMUSCULA
R
3
PA
lorazepam
1
lorazepam intensol
1
GEODON ORAL
3
loxapine succinate
1
guanfacine
1
LUNESTA
3
guanidine
1
maprotiline
1
HALCION
3
MARPLAN
3
HALDOL
3
PA
METADATE CD
3
HALDOL
DECANOATE
3
PA
metadate er
1
methamphetamine
1
haloperidol
1
METHYLIN
3
haloperidol
decanoate
1
methylphenidate
1
mirtazapine
1
haloperidol lactate
injection
1
modafinil
1
haloperidol lactate
oral
1
molindone
1
NARDIL
3
HETLIOZ
4
nefazodone
1
imipramine hcl
1
NORPRAMIN
3
imipramine pamoate
1
nortriptyline
1
INTERMEZZO
3
NUPLAZID
4
PA; LA
INTUNIV ER
3
NUVIGIL
3
PA; QL
QL
PA
PA
PA; LA
25
QL
PA; QL
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
olanzapine
1
olanzapinefluoxetine
1
OLEPTRO ER
3
QL
REMERON
SOLTAB
3
RESTORIL
3
REXULTI
3
ORAP
3
RISPERDAL
3
oxazepam
1
3
QL
paliperidone
1
RISPERDAL
CONSTA
PAMELOR
3
RISPERDAL MTAB
3
QL
PARNATE
3
1
risperidone oral
solution
1
paroxetine hcl
PAXIL
3
1
PAXIL CR
3
risperidone oral
tablet
perphenazine
1
risperidone oral
1
perphenazineamitriptyline
1
RITALIN
3
PEXEVA
3
RITALIN LA
3
phenelzine
1
ROZEREM
3
QL
pimozide
1
SAPHRIS (BLACK
CHERRY)
3
ST; QL
PRISTIQ
3
SARAFEM
3
procentra
1
seconal sodium
1
protriptyline
1
3
PROZAC
3
SEROQUEL ORAL
TABLET 100 MG,
200 MG, 25 MG,
300 MG
3
PROVIGIL
PROZAC WEEKLY
3
1
quetiapine oral
tablet 100 mg, 200
mg, 25 mg, 300 mg
1
SEROQUEL ORAL
TABLET 400 MG,
50 MG
3
quazepam
SEROQUEL XR
2
sertraline
1
quetiapine oral
tablet 400 mg, 50 mg
1
SILENOR
3
QUILLICHEW ER
3
SONATA
3
QUILLIVANT XR
3
STRATTERA
3
REMERON
3
SURMONTIL
3
PA
QL
PA
PA; QL
PA; QL
PA; QL
QL
26
Requirements
/ Limits
PA
QL
QL
QL
PA
Drug Name
Drug
Tier
Requirements
/ Limits
SYMBYAX
3
zolpidem
1
temazepam
1
ZOLPIMIST
3
PA
thioridazine
1
ZYPREXA
3
QL
thiothixene
1
3
TOFRANIL
3
ZYPREXA
RELPREVV
TRANXENE TTAB
3
ZYPREXA ZYDIS
3
tranylcypromine
1
CARDIOVASCULAR,
HYPERTENSION & LIPIDS
trazodone
1
ANTIARRHYTHMIC AGENTS
triazolam
1
amiodarone
1
trifluoperazine
1
BETAPACE
3
trimipramine
1
BETAPACE AF
3
TRINTELLIX
3
1
VALIUM
3
disopyramide
phosphate
venlafaxine
1
flecainide
1
VERSACLOZ
3
mexiletine
1
VIIBRYD
3
PA
MULTAQ
3
VRAYLAR
3
PA; QL
NORPACE
3
VYVANSE
3
2
WELLBUTRIN SR
3
WELLBUTRIN XL
3
NORPACE CR
ORAL CAPSULE,
EXTENDED
RELEASE 100 MG
XANAX
3
3
XANAX XR
3
XYREM
4
NORPACE CR
ORAL CAPSULE,
EXTENDED
RELEASE 150 MG
zaleplon
1
pacerone
1
zenzedi oral tablet
10 mg, 5 mg
1
procainamide
1
propafenone
1
ZENZEDI ORAL
TABLET 15 MG,
2.5 MG, 20 MG, 30
MG, 7.5 MG
3
quinidine gluconate
injection
1
1
ziprasidone hcl
1
quinidine gluconate
oral
ZOLOFT
3
quinidine sulfate
1
RYTHMOL
3
PA
PA; LA
QL
Drug Name
27
Drug
Tier
Requirements
/ Limits
QL
PA
PA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
RYTHMOL SR
3
AZOR
3
sotalol af
1
benazepril
1
SOTALOL
INTRAVENOUS
3
benazeprilhydrochlorothiazide
1
sotalol oral
1
BENICAR
3
PA
SOTYLIZE
3
BENICAR HCT
3
PA
TIKOSYN
3
betaxolol
1
ANTIHYPERTENSIVE THERAPY
BIDIL
3
ACCUPRIL
3
bisoprolol fumarate
1
ACCURETIC
3
1
acebutolol
1
bisoprololhydrochlorothiazide
ACEON
3
BREVIBLOC
3
ADALAT CC
3
BREVIBLOC IN
NACL (ISO-OSM)
3
afeditab cr
1
bumetanide injection
1
ALDACTAZIDE
3
bumetanide oral
1
ALDACTONE
3
BYSTOLIC
3
ALTACE
3
CALAN
3
amiloride
1
CALAN SR
3
amiloridehydrochlorothiazide
1
candesartan
1
amlodipine
1
candesartanhydrochlorothiazid
1
amlodipinebenazepril
1
captopril
1
amlodipinevalsartan
1
captoprilhydrochlorothiazide
1
amlodipinevalsartan-hcthiazid
1
CARDENE IV
3
3
ATACAND
3
CARDENE IV IN
DEXTROSE
ATACAND HCT
3
3
atenolol
1
CARDENE IV IN
SODIUM
CHLORIDE
atenololchlorthalidone
1
CARDIZEM
3
CARDIZEM CD
3
AVALIDE
3
CARDIZEM LA
3
PA
AVAPRO
3
28
PA
PA
PA
PA
PA
PA
Drug Name
Drug
Tier
CARDURA
3
CARDURA XL
3
carvedilol
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
DIBENZYLINE
3
diltiazem
1
1
DIOVAN
3
CATAPRES
3
DIOVAN HCT
3
CATAPRES-TTS-1
3
DIURIL
3
CATAPRES-TTS-2
3
DIURIL IV
3
CATAPRES-TTS-3
3
doxazosin
1
chlorothiazide
1
DUTOPROL
2
chlorothiazide
sodium
1
DYAZIDE
3
DYRENIUM
3
chlorthalidone
1
EDARBI
3
PA
CLEVIPREX
INTRAVENOUS
EMULSION 25
MG/50 ML
3
EDARBYCLOR
3
PA
EDECRIN
3
enalapril maleate
1
CLEVIPREX
INTRAVENOUS
EMULSION 50
MG/100 ML
3
enalaprilat
1
enalaprilhydrochlorothiazide
1
clonidine
1
EPANED
3
clonidine hcl
1
eplerenone
1
clorpres oral tablet
0.1-15 mg, 0.2-15
mg
1
epoprostenol
(glycine)
4
eprosartan
1
CLORPRES ORAL
TABLET 0.3-15
MG
3
esmolol
1
ethacrynate sodium
1
COREG
3
EXFORGE
3
COREG CR
3
EXFORGE HCT
3
CORGARD
3
felodipine
1
corlopam
1
FLOLAN
4
CORZIDE
3
fosinopril
1
COZAAR
3
1
DEMADEX
3
fosinoprilhydrochlorothiazide
DEMSER
3
furosemide injection
1
furosemide oral
1
PA
PA
PA
29
PA
PA
PA; LA
PA
PA; LA
PA
Drug Name
Drug
Tier
Requirements
/ Limits
guanfacine
1
MAVIK
3
HEMANGEOL
4
MAXZIDE
3
hydralazine injection
1
MAXZIDE-25MG
3
hydralazine oral
1
methyclothiazide
1
hydrochlorothiazide
1
methyldopa
1
HYZAAR
3
1
indapamide
1
methyldopahydrochlorothiazide
INDERAL LA
3
methyldopate
1
INDERAL XL
3
metolazone
1
INNOPRAN XL
2
metoprolol succinate
1
INSPRA
3
metoprolol tahydrochlorothiaz
1
irbesartan
1
1
metoprolol tartrate
intravenous
1
irbesartanhydrochlorothiazide
1
metoprolol tartrate
oral
1
isradipine
labetalol
intravenous
1
MICARDIS
3
MICARDIS HCT
3
labetalol oral
1
MICROZIDE
3
LASIX
3
MINIPRESS
3
LEVATOL
3
minoxidil
1
lisinopril
1
moexipril
1
lisinoprilhydrochlorothiazide
1
moexiprilhydrochlorothiazide
1
LOPRESSOR HCT
3
nadolol
1
LOPRESSOR
INTRAVENOUS
3
nadololbendroflumethiazide
1
LOPRESSOR
ORAL
3
nicardipine
intravenous
1
losartan
1
nicardipine oral
1
losartanhydrochlorothiazide
1
nifedical xl
1
LOTENSIN
3
nifedipine
1
LOTENSIN HCT
3
nimodipine
1
LOTREL
3
nisoldipine
1
PA
PA
PA
Drug Name
30
Drug
Tier
Requirements
/ Limits
PA
PA
PA
PA
Drug Name
Drug
Tier
NORVASC
3
NYMALIZE
3
ORENITRAM
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
TEKTURNA HCT
3
PA
telmisartan
1
4
PA; LA
1
papaverine
1
PA
telmisartanamlodipine
perindopril
erbumine
1
telmisartanhydrochlorothiazid
1
phenoxybenzamine
1
TENEX
3
phentolamine
1
TENORETIC 100
3
pindolol
1
TENORETIC 50
3
prazosin
1
TENORMIN
3
PRESTALIA
3
terazosin
1
PRINIVIL
3
TIAZAC
3
PROCARDIA
3
timolol maleate
1
PROCARDIA XL
3
TOPROL XL
3
propranolol
intravenous
1
torsemide
1
trandolapril
1
propranolol oral
1
1
propranololhydrochlorothiazid
1
trandolaprilverapamil
1
quinapril
1
triamterenehydrochlorothiazid
quinaprilhydrochlorothiazide
1
TRIBENZOR
3
TWYNSTA
3
ramipril
1
UPTRAVI
4
REMODULIN
4
valsartan
1
reserpine
1
1
SECTRAL
3
valsartanhydrochlorothiazide
SODIUM
EDECRIN
3
VASERETIC
3
VASOTEC
3
spironolactone
1
veletri
4
PA; LA
spironolactonhydrochlorothiaz
1
verapamil
intravenous
1
PA
SULAR
3
verapamil oral
1
TARKA
3
VERELAN
3
TEKTURNA
3
VERELAN PM
3
PA
PA
PA
PA; LA
PA
ST
31
ST
PA
PA; LA
Drug Name
Drug
Tier
ZEBETA
3
ZESTORETIC
3
ZESTRIL
3
ZIAC
3
Requirements
/ Limits
CARDIAC GLYCOSIDES
digitek
1
digox
1
digoxin injection
1
digoxin oral
1
LANOXIN
INJECTION
3
LANOXIN ORAL
3
LANOXIN
PEDIATRIC
3
PA
PA
PA
COAGULATION THERAPY
Drug Name
Drug
Tier
Requirements
/ Limits
CEPROTIN (BLUE
BAR)
4
PA; LA
CEPROTIN
(GREEN BAR)
4
PA; LA
cilostazol
1
clopidogrel
1
CORIFACT
4
COUMADIN
3
CYKLOKAPRON
3
dipyridamole
1
DURLAZA
3
EFFIENT
2
ELIQUIS
2
QL
ELOCTATE
4
PA; LA
enoxaparin
4
PA; LA
PA
PA
ADVATE
4
PA; LA
FEIBA NF
4
AFSTYLA
4
PA; LA
fondaparinux
4
AGGRENOX
3
FRAGMIN
4
ALPHANATE
4
PA; LA
HELIXATE FS
4
PA; LA
ALPHANINE SD
4
PA; LA
HEMOFIL M HIGH
4
PA; LA
AMICAR
3
HEMOFIL M LOW
4
PA; LA
aminocaproic acid
1
PA
HEMOFIL M MID
4
PA; LA
ARGATROBAN
3
PA
4
PA; LA
ARGATROBAN IN
0.9 % SOD CHLOR
3
PA
HEMOFIL M
SUPER HIGH
hep flush-10 (pf)
1
PA
ARGATROBAN IN
NACL (ISO-OS)
3
heparin (porcine)
1
PA
1
PA
ARIXTRA
4
heparin (porcine) in
5 % dex
aspirin-dipyridamole
1
1
PA
BEBULIN
4
PA; LA
heparin (porcine) in
nacl (pf)
BENEFIX
4
PA; LA
heparin flush
1
PA
BRILINTA
2
heparin
flush(porcine)0.9nacl
1
PA
32
PA; LA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
heparin lock flush
1
PA
NPLATE
4
PA; LA
heparin lock flush
(porcine)
1
PA
OBIZUR
4
PA
pentoxifylline
1
heparin
lockflush(porcine)(pf
)
1
PA
PHYTONADIONE
(VITAMIN K1)
3
HEPARIN(PORCIN
E) IN 0.45% NACL
INTRAVENOUS
PARENTERAL
SOLUTION 12,500
UNIT/250 ML
3
PA
PLAVIX
3
PRADAXA
3
QL
PROFILNINE
4
PA; LA
PROMACTA
4
PA; LA
protamine
1
PA
heparin(porcine) in
0.45% nacl
intravenous
parenteral solution
25,000 unit/250 ml,
25,000 unit/500 ml
1
RECOMBINATE
4
PA; LA
RIASTAP
4
PA; LA
RIXUBIS
4
PA; LA
SAVAYSA
3
heparin, porcine (pf)
1
PA
ticlopidine
1
HUMATE-P
4
PA; LA
tranexamic acid
1
PA
IDELVION
4
PA
TRETTEN
4
PA; LA
IXINITY
4
PA
vitamin k
1
PA
jantoven
1
vitamin k1
1
PA
KCENTRA
3
PA
VONVENDI
4
PA; LA
KOATE-DVI
4
PA; LA
warfarin
1
KOGENATE FS
4
PA; LA
WILATE
4
KOVALTRY
4
PA; LA
XARELTO
2
LOVENOX
4
XYNTHA
4
PA; LA
MEPHYTON
2
4
PA; LA
MONOCLATE-P
4
XYNTHA
SOLOFUSE
monoject prefill (pf)
1
ZONTIVITY
3
PA
monoject prefill
advanced (pf)
1
MONONINE
4
PA; LA
NOVOEIGHT
4
PA
NOVOSEVEN RT
4
PA; LA
PA
PA; LA
PA
PA; LA
LIPID/CHOLESTEROL LOWERING
AGENTS
ALTOPREV
3
amlodipineatorvastatin
1
ANTARA
3
33
PA
Drug Name
Drug
Tier
Requirements
/ Limits
atorvastatin
1
niacin
1
CADUET
3
NIACOR
3
cholestyramine (with
sugar)
1
3
cholestyramine light
1
NIASPAN
EXTENDEDRELEASE
COLESTID
3
omega-3 acid ethyl
esters
1
PA
COLESTID
FLAVORED
3
PRALUENT PEN
4
PA; LA; QL
colestipol
1
PRALUENT
SYRINGE
4
PA; LA; QL
fenofibrate
micronized
1
PRAVACHOL
3
fenofibrate
nanocrystallized
1
pravastatin
1
prevalite
1
FENOFIBRATE
ORAL CAPSULE
3
QUESTRAN
3
3
fenofibrate oral
tablet
1
QUESTRAN
LIGHT
PA; LA; QL
1
REPATHA
SURECLICK
4
fenofibric acid
fenofibric acid
(choline)
1
REPATHA
SYRINGE
4
PA; LA; QL
FENOGLIDE
3
rosuvastatin
1
FIBRICOR
3
simvastatin
1
fluvastatin
1
TRICOR
3
gemfibrozil
1
TRIGLIDE
3
JUXTAPID
4
PA; QL
TRILIPIX
3
KYNAMRO
4
PA; LA
VASCEPA
3
PA
LESCOL
3
VYTORIN 10-10
3
PA
LESCOL XL
3
VYTORIN 10-20
3
PA
LIPITOR
3
VYTORIN 10-40
3
PA
LIPOFEN
3
PA
VYTORIN 10-80
3
PA
LIVALO
3
PA; QL
WELCHOL
2
LOFIBRA
3
ZETIA
2
LOPID
3
ZOCOR
3
lovastatin
1
PA
PA
Drug Name
34
Drug
Tier
Requirements
/ Limits
PA
QL
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
MISCELLANEOUS
CARDIOVASCULAR AGENTS
nitroglycerin
translingual
1
CORLANOR
3
PA; QL
NITROLINGUAL
3
ENTRESTO
3
PA
NITROMIST
3
NATRECOR
3
PA
NITROSTAT
3
RANEXA
2
nitro-time
1
VECAMYL
3
DERMATOLOGICALS/TOPICAL
THERAPY
DILATRATE-SR
2
ANTIPSORIATIC / ANTISEBORRHEIC
ISOCHRON
3
acitretin
1
ISORDIL
3
calcipotriene
1
QL
ISORDIL
TITRADOSE
3
calcipotrienebetamethasone
1
QL
isosorbide dinitrate
1
calcitrene
1
QL
isosorbide
mononitrate
1
calcitriol
1
QL
COAL TAR
3
MINITRAN
3
COSENTYX
4
PA; LA
nitro-bid
1
4
PA
NITRO-DUR
TRANSDERMAL
PATCH 24 HOUR
0.1 MG/HR, 0.2
MG/HR, 0.4
MG/HR, 0.6
MG/HR
3
COSENTYX (2
SYRINGES)
COSENTYX PEN
4
PA; LA
COSENTYX PEN
(2 PENS)
4
PA
DOVONEX
3
PA; QL
NITRO-DUR
TRANSDERMAL
PATCH 24 HOUR
0.3 MG/HR, 0.8
MG/HR
2
drithocreme hp
1
ENSTILAR
3
EPIFOAM
3
1
nitroglycerin in 5 %
dextrose
1
PA
hydrocortisonepramoxine
OVACE
3
nitroglycerin
intravenous
1
PA
OVACE PLUS
SHAMPOO
3
nitroglycerin oral
1
nitroglycerin
transdermal
1
NITRATES
35
Requirements
/ Limits
PA; QL
Drug Name
Drug
Tier
OVACE PLUS
TOPICAL
CLEANSER,EXTE
NDED RELEASE
3
OVACE PLUS
TOPICAL CREAM
3
OVACE PLUS
TOPICAL FOAM
3
OVACE PLUS
TOPICAL LOTION
3
OVACE PLUS
WASH
3
PRAMOSONE
Requirements
/ Limits
PA
Drug Name
Drug
Tier
TALTZ SYRINGE
(3 PACK)
4
TERSI FOAM
3
VECTICAL
3
ZITHRANOL
3
ZITHRANOL-RR
3
BURN THERAPY
SILVADENE
3
silver sulfadiazine
1
ssd
1
3
thermazene
1
PRAMOSONE E
3
KERATOLYTICS
PROMISEB
COMPLETE
3
BENSAL HP
3
INOVA 4-1
3
seb-prev
1
INOVA 8-2
3
selenium sulfide
1
KERALYT RX
3
SELRX
3
3
KERALYT SCALP
COMPLETE
3
SORIATANE
SORILUX
3
PA; QL
PODOCON
3
STELARA
4
PA; LA; QL
3
sulfacetamide
sodium
1
POTASSIUM
HYDROXIDE
salacyn
1
TACLONEX
3
QL
SALEX
3
TALTZ
AUTOINJECTOR
4
PA; LA
salicylic acid
1
1
TALTZ
AUTOINJECTOR
(2 PACK)
4
PA; LA
salicylic acid erceramides
SALKERA
3
TALTZ
AUTOINJECTOR
(3 PACK)
4
salvax
1
SALVAX DUO
PLUS
3
TALTZ SYRINGE
4
PA; LA
ULTRASAL-ER
3
TALTZ SYRINGE
(2 PACK)
4
PA; LA
VIRASAL
3
PA; LA
36
Requirements
/ Limits
PA; LA
QL
Drug Name
Drug
Tier
Requirements
/ Limits
MISCELLANEOUS
DERMATOLOGICALS
Drug Name
Drug
Tier
fluorouracil topical
solution
1
8-MOP
4
GORDONS UREA
3
ALEVICYN
ANTIPRURITIC
3
hpr
1
hpr plus
1
ALUVEA
3
hpr plus hydrogel
1
ammonium lactate
1
3
ATOPICLAIR
3
HPR PLUS-MB
HYDROGEL
ATRAPRO CP
3
HYDRO 35
3
ATRAPRO
HYDROGEL
3
HYDRO 40
3
KERAFOAM
3
avo cream
1
KERALAC
3
BIAFINE
EMULSION
3
lactic acid
1
bp-50% urea
1
lactic acid e
1
CARAC
3
latrix
1
cem-urea
1
LEVULAN
3
CONDYLOX
2
LOUTREX
3
CORTANE-B
3
luxamend
1
DERMASORB XM
COMPLETE KIT
3
mac
1
mb hydrogel
1
diclofenac sodium
1
1
doxepin
1
mb hydrogel
(cyclomethicone)
EFUDEX
3
methoxsalen rapid
1
eletone
1
methyl salicylate
1
ELIDEL
3
NEOSALUS
3
emulsion sb
1
OXSORALEN
3
EPICERAM
3
OXSORALEN
ULTRA
3
FLUOROPLEX
3
PANRETIN
4
FLUOROURACIL
TOPICAL CREAM
0.5 %
3
PICATO
3
podofilox
1
fluorouracil topical
cream 5 %
1
PRESERA
3
PROMISEB
3
PA
PA
QL
37
Requirements
/ Limits
QL
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
PROTOPIC
3
QL
XCLAIR
3
pruclair
1
ZANABIN
2
prudoxin
1
ZONALON
3
PA
prumyx
1
THERAPY FOR ACNE
prutect
1
ABSORICA
3
PA
QUTENZA
4
ACANYA
3
rea lo 39
1
ACZONE
3
rea lo 40
1
adapalene
1
REGRANEX
3
ATRALIN
3
remeven
1
3
RYNODERM
3
AVAR LS
TOPICAL
CLEANSER
silver nitrate
1
1
AVAR LS
TOPICAL FOAM
3
silver nitrate
applicators
3
sonafine
1
AVAR LS
TOPICAL PADS,
MEDICATED
3
SOLARAZE
tacrolimus
1
avar topical cleanser
1
TOLAK
3
AVAR TOPICAL
FOAM
3
TROPAZONE
LOTION
3
3
umecta
1
AVAR TOPICAL
PADS,
MEDICATED
UMECTA PD
3
AVAR-E GREEN
3
URAMAXIN
3
AVAR-E LS
3
URAMAXIN GT
3
avita
1
urea
1
AZELEX
2
urea nail stick
1
BENZACLIN
3
urea-hyaluronate
sodium
1
BENZACLIN
PUMP
3
ure-k
1
BENZAMYCIN
3
UTOPIC
3
3
UVADEX
3
PA
BENZAMYCINPA
K
VALCHLOR
4
PA; LA; QL
BENZEFOAM
3
VEREGEN
3
PA
PA
PA
QL
38
Drug
Tier
Requirements
/ Limits
PA
PA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
METROGEL
3
METROLOTION
3
metronidazole
1
MIRVASO
3
myorisan
1
neuac
1
NORITATE
2
NUOX
3
ONEXTON
3
PACNEX
3
PLEXION
3
PLEXION
CLEANSING
CLOTHS
3
PR BENZOYL
PEROXIDE
3
RETIN-A
3
Requirements
/ Limits
BENZEFOAM
ULTRA
3
benzepro
1
BENZEPRO
(MICROSPHERES)
3
benzoyl peroxide
1
bp 10-1
1
bpo
1
claravis
1
cleansing wash
1
CLEOCIN T
3
CLINDACIN ETZ
3
clindacin p
1
CLINDACIN PAC
3
CLINDAGEL
3
clindamycin
phosphate
1
clindamycin-benzoyl
peroxide
1
RETIN-A MICRO
3
3
DIFFERIN
3
RETIN-A MICRO
PUMP
DUAC
3
rosadan
1
EPIDUO
2
ROSANIL
3
EPIDUO FORTE
3
ROSULA
3
PA
ery pads
1
1
PA
erygel
1
rosula cleansing
cloths
erythromycin with
ethanol
1
SOOLANTRA
3
ss 10-2
1
erythromycinbenzoyl peroxide
1
sss 10-5
1
3
sulfacetamide
sodium-sulfur
1
EVOCLIN
FABIOR
3
1
FINACEA
3
sulfacetamide sodsulfur-urea
INOVA
3
sulfacetamidesulfur-cleansr23
1
METROCREAM
3
PA
39
PA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
lidocaineepinephrine
1
lidocaine-prilocaine
1
LIDOCAINETETRACAINE
3
LIDODERM
3
lido-k
1
lidopin topical
cream 3 %
1
Requirements
/ Limits
sulfacleanse 8-4
1
sulfact na-sulavobnz-otn-ocsa
1
SUMADAN
3
SUMADAN XLT
3
SUMAXIN
3
SUMAXIN CP
3
SUMAXIN TS
3
TAZORAC
3
1
LIDOPIN TOPICAL
CREAM 3.25 %
3
tretinoin
tretinoin
microspheres
1
LIDORX
3
LIDOVEX
3
TRETIN-X
3
LIVIXIL PAK
3
PA
TRETIN-X CREAM
KIT
3
LP LITE PAK
3
PA
VANOXIDE-HC
3
lta pre-attached
1
VELTIN
3
NOVACORT
(WITH ALOE)
3
zenatane
1
PLIAGLIS
3
zencia
1
relador pak
1
ZIANA
3
relador pak plus
1
SYNERA
3
XYLOCAINE
3
PA
XYLOCAINEEPINEPHRINE
3
PA
XYLOCAINE-MPF
INJECTION
SOLUTION 10
MG/ML (1 %), 20
MG/ML (2 %), 5
MG/ML (0.5 %)
3
XYLOCAINE-MPF
INJECTION
SOLUTION 15
MG/ML (1.5 %)
3
PA
ZINGO
3
PA
PA
TOPICAL ANESTHETICS
BUCALSEP
3
ethyl chloride
1
glydo
1
lidocaine
1
lidocaine (pf)
1
PA
lidocaine hcl
injection
1
PA
lidocaine hcl mucous
membrane
1
lidocaine hcl topical
1
lidocaine hclhydrocortison ac
1
lidocaine viscous
1
40
PA
PA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
TOPICAL ANTIBACTERIALS
LOPROX
3
ALTABAX
3
LOTRISONE
3
CENTANY
3
LUZU
3
CENTANY AT
3
MENTAX
3
CORTISPORIN
2
3
gentamicin
1
NAFTIFINE
TOPICAL CREAM
1%
KLARON
3
1
mupirocin
1
naftifine topical
cream 2 %
mupirocin calcium
1
NAFTIN
3
NEO-SYNALAR
3
NIZORAL
3
NEO-SYNALAR
KIT
3
nyamyc
1
NYATA
3
sulfacetamide
sodium (acne)
1
nystatin
1
SULFAMYLON
3
nystatintriamcinolone
1
TOPICAL ANTIFUNGALS
nystop
1
ciclodan
1
oxiconazole
1
ciclopirox
1
OXISTAT
3
ciclopirox-urecamph-menth-euc
1
PENLAC
3
clotrimazole
1
TRIACETIN
3
clotrimazolebetamethasone
1
TRIPLE DYE
3
VUSION
3
CNL 8 NAIL
3
XOLEGEL
3
econazole
1
ECOZA
3
ERTACZO
PA
Requirements
/ Limits
PA; QL
PA; QL
TOPICAL ANTIVIRALS
acyclovir
1
3
DENAVIR
3
EXELDERM
3
XERESE
3
EXODERM
3
ZOVIRAX
3
EXTINA
3
PA
TOPICAL CORTICOSTEROIDS
JUBLIA
3
PA
ala-cort
1
KERYDIN
3
PA
ALA-SCALP
3
ketoconazole
1
alclometasone
1
PA; QL
41
Drug Name
Drug
Tier
amcinonide
1
apexicon e
1
AQUA GLYCOLIC
HC
3
betamethasone
dipropionate
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
CLOCORTOLONE
PIVALATE
3
clodan
1
CLODERM
3
1
CORDRAN
3
QL
1
CORDRAN TAPE
SMALL ROLL
3
betamethasone
valerate
cormax
1
PA
betamethasone,
augmented
1
CUTIVATE
3
CAPEX
3
3
clobetasol scalp
1
PA
DERMASMOOTHE/FS
BODY OIL
clobetasol topical
cream
1
PA
3
clobetasol topical
foam
1
PA; QL
DERMASMOOTHE/FS
SCALP OIL
3
clobetasol topical
gel
1
DERMASORB HC
COMPLETE KIT
3
clobetasol topical
lotion
1
DERMASORB TA
COMPLETE KIT
DERMATOP
3
clobetasol topical
ointment
1
DESONATE
3
desonide
1
clobetasol topical
shampoo
1
PA
DESOWEN
3
clobetasol topical
spray,non-aerosol
1
PA
desoximetasone
1
diflorasone
1
clobetasol-emollient
topical cream
1
PA
DIPROLENE
3
DIPROLENE AF
3
clobetasol-emollient
topical foam
1
PA; QL
ELOCON
3
CLOBEX TOPICAL
LOTION
3
PA; ST
fluocinolone
1
1
CLOBEX TOPICAL
SHAMPOO
3
fluocinolone and
shower cap
fluocinonide
1
CLOBEX TOPICAL
SPRAY,NONAEROSOL
3
fluocinonide-e
1
flurandrenolide
1
fluticasone
1
PA
PA
PA
PA
PA
42
PA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
halobetasol
propionate
1
triamcinolone
acetonide
1
HALOG
3
trianex
1
hydrocortisone
1
triderm
1
hydrocortisone
butyrate
1
ULTRAVATE
3
ULTRAVATE X
3
hydrocortisone
butyr-emollient
1
VANOS
3
ST
hydrocortisone
valerate
1
VERDESO
3
ST
hydrocortisone-min
oil-wht pet
1
SANTYL
KENALOG
3
TOPICAL SCABICIDES /
PEDICULICIDES
LOCOID
3
ELIMITE
3
LOCOID
LIPOCREAM
3
EURAX
2
lindane
1
LUXIQ
3
LYCELLE
3
mometasone
1
malathion
1
OLUX
3
PA; ST; QL
NATROBA
3
OLUX-E
3
PA; ST; QL
OVIDE
3
PANDEL
3
permethrin
1
prednicarbate
1
SKLICE
3
PSORCON
3
spinosad
1
scalacort
1
ULESFIA
3
SCALACORT DK
3
SYNALAR
3
SYNALAR
CREAM KIT
3
SYNALAR
OINTMENT KIT
3
SYNALAR TS
3
TEMOVATE
3
TEXACORT
3
TOPICORT
3
TOPICAL ENZYMES
3
DIAGNOSTICS &
MISCELLANEOUS AGENTS
ANTIDOTES
ATROPEN
3
DUODOTE
3
PA
IRRIGATING SOLUTIONS
PA
lactated ringers
1
neomycin-polymyxin
b gu
1
43
PA
Drug Name
Drug
Tier
NEOSPORIN GU
IRRIGANT
3
PHYSIOLYTE
3
PHYSIOSOL
IRRIGATION
3
ringers
1
SORBITOL
3
SORBITOLMANNITOL
3
VASHE WOUND
THERAPY
3
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
PA
disulfiram
1
etidronate disodium
1
EVOXAC
3
EXJADE
4
FERRIPROX
4
FERRLECIT
3
PA
GLASSIA
4
PA; LA
HYLENEX
3
PA
ic green
1
PA; LA
INCRELEX
4
indocyanine green
1
acamprosate
1
INFASURF
3
acetic acid
1
JADENU
4
ACTONEL
3
1
ADAGEN
4
levocarnitine (with
sugar)
AGRYLIN
3
1
alendronate
1
levocarnitine
intravenous
AMPHADASE
3
levocarnitine oral
1
anagrelide
1
LIPOCHOL PLUS
3
ANTABUSE
3
LITHOSTAT
3
ARALAST NP
4
PA; LA
METOPIRONE
3
bd pre-filled normal
saline
1
PA
midodrine
1
1
PA
BUPHENYL
3
monoject 0.9%
sodium chloride
caffeine citrated
1
monoject prefill
advanced ns
1
PA
CARBAGLU
4
1
PA
CARNITOR
(SUGAR-FREE)
3
monoject prefill
saline flush
normal saline flush
1
PA
CARNITOR
INTRAVENOUS
3
NORTHERA
4
LA; QL
CARNITOR ORAL
3
ORFADIN
4
PA
cevimeline
1
pilocarpine hcl
1
CHEMET
3
PROLASTIN-C
4
PA
PA
PA
LA
PA
44
PA; LA
PA
PA
PA
Drug Name
Drug
Tier
Requirements
/ Limits
RADIOGARDASE
3
RAVICTI
4
PA; LA
RECLAST
4
PA; LA
RILUTEK
3
riluzole
1
risedronate
1
SALAGEN
3
SINOGRAFIN
3
sodium chlor 0.9%
bacteriostat
1
sodium chloride 0.9
% injection solution
1
sodium chloride 0.9
% injection syringe
1
SODIUM
CHLORIDE 0.9 %
INJECTION
SYRINGE, WITH
SWAB CAP
3
sodium chloride 0.9
% intravenous
parenteral solution
1
sodium chloride 0.9
% intravenous
piggyback
1
sodium ferric
gluconat-sucrose
1
PA
sodium
phenylbutyrate
1
PA
SOLIRIS
4
SURVANTA
3
SWABFLUSH
3
SYPRINE
3
syrex sodium
chloride 0.9%
1
THIOLA
4
Drug Name
Drug
Tier
Requirements
/ Limits
water for irrigation,
sterile
1
XURIDEN
4
PA; LA
ZEMAIRA
4
PA; LA
zoledronic acidmannitol-water
4
PA; LA
SMOKING DETERRENTS
PA
PA
PA
CHANTIX
0
ACA
CHANTIX
CONTINUING
MONTH BOX
0
ACA
CHANTIX
STARTING
MONTH BOX
0
ACA
NICODERM CQ
0
ACA; OTC
NICORETTE
0
ACA; OTC
nicotine
0
ACA; OTC
NICOTINE
(POLACRILEX)
0
ACA; OTC
NICOTROL
0
ACA
NICOTROL NS
0
ACA
QUIT 2
0
ACA; OTC
QUIT 4
0
ACA; OTC
ZYBAN
3
EAR, NOSE & THROAT
MEDICATIONS
PA; LA
ASTEPRO
3
azelastine
1
PA
BACTROBAN
NASAL
3
PA
chlorhexidine
gluconate
1
CLINPRO 5000
3
45
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
DEBACTEROL
3
sf
1
denta 5000 plus
1
sf 5000 plus
1
dentagel
1
sodium fluoride
1
EPISIL
3
1
fluoridex daily
defense
1
triamcinolone
acetonide
TYZINE
3
FLUORIDEX
SENSITIVITY
RELIEF
3
GELCLAIR
3
GELX
3
ipratropium bromide
Requirements
/ Limits
MISCELLANEOUS OTIC
PREPARATIONS
acetasol hc
1
acetic acid
1
acetic acidaluminum acetate
1
1
MUGARD
3
CETRAXAL
3
olopatadine
1
ciprofloxacin hcl
1
ORAFATE
3
DERMOTIC OIL
3
oralone
1
1
ORAMAGICRX
3
fluocinolone
acetonide oil
PATANASE
3
1
PERIDEX
3
hydrocortisoneacetic acid
periogard
1
ofloxacin
1
pilocarpine hcl
1
PREVIDENT
3
PREVIDENT 5000
BOOSTER PLUS
3
PREVIDENT 5000
DRY MOUTH
PA
PA
OTIC STEROID / ANTIBIOTIC
CIPRO HC
3
CIPRODEX
3
COLY-MYCIN S
3
3
neomycinpolymyxin-hc
1
PREVIDENT 5000
ENAMEL
PROTECT
3
ENDOCRINE/DIABETES
PREVIDENT 5000
SENSITIVE
3
PROTHELIAL
4
Q-CARE RX Q4
SALAGEN
ADRENAL HORMONES
ACTHAR H.P.
4
CORTEF
3
cortisone
1
3
CORTROSYN
3
PA
3
cosyntropin injection
1
PA
LA
46
PA; LA; QL
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
PA
propylthiouracil
1
SSKI
3
TAPAZOLE
3
Requirements
/ Limits
COSYNTROPIN
INTRAVENOUS
3
deltasone
1
dexamethasone
1
dexamethasone
intensol
1
BLOOD GLUCOSE MONITORING
DEVICES & SUPPLIES
PA; OTC; QL
2
DEXPAK 13 DAY
2
ACCU-CHEK
AVIVA PLUS
TEST STRP
3
DEXPAK 10 DAY
DEXPAK 6 DAY
2
3
PA; OTC; QL
fludrocortisone
1
ACCU-CHEK
COMPACT TEST
hydrocortisone
1
3
PA; OTC; QL
MEDROL (PAK)
3
ACCU-CHEK
SMARTVIEW
TEST STRIP
MEDROL ORAL
TABLET 16 MG, 32
MG, 4 MG, 8 MG
3
ACCUTREND
GLUCOSE
3
PA; OTC; QL
3
PA; OTC
MEDROL ORAL
TABLET 2 MG
2
ADVANCED
GLUC METER
TEST STRIP
methylprednisolone
1
3
PA; OTC; QL
millipred dp
1
ADVOCATE REDICODE
MILLIPRED ORAL
SOLUTION
3
ADVOCATE TEST
STRIPS
3
PA; OTC; QL
millipred oral tablet
1
AGAMATRIX
AMP TEST STRIPS
3
PA; OTC
ORAPRED ODT
3
ASSURE 4 STRIPS
3
PA; OTC; QL
PEDIAPRED
3
3
PA; OTC; QL
prednisolone
1
ASSURE
PLATINUM
prednisolone sodium
phosphate
1
ASSURE PRISM
MULTI STRIP
3
PA; OTC
prednisone
1
BG-STAR
3
PA; OTC; QL
prednisone intensol
1
3
PA; OTC; QL
RAYOS
3
BIONIME
RIGHTEST TEST
STRIPS
TRIESENCE (PF)
3
3
PA; OTC; QL
veripred 20
1
BLOOD GLUCOSE
TEST
BREEZE 2 TEST
STRIPS
3
PA; OTC; QL
PA
ANTITHYROID AGENTS
methimazole
1
47
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
EMBRACE
BLOOD GLUCOSE
SYSTEM
3
PA; OTC; QL
EMBRACE EVO
TEST STRIPS
3
PA; OTC
CARESENS N
TEST STRIPS
3
PA; OTC
CLEVER CHOICE
MICRO TEST
STRIP
3
PA; OTC; QL
CLEVER CHOICE
PRO
3
PA; OTC; QL
EMBRACE PRO
TEST STRIPS
3
PA; OTC
CLEVER CHOICE
TEST STRIPS
3
PA; OTC; QL
EVENCARE G2
3
PA; OTC; QL
PA; OTC; QL
3
PA; OTC; QL
EVENCARE G3
TEST
3
CLEVER CHOICE
VOICE+ TEST
3
PA; OTC
CONTOUR NEXT
STRIPS
3
PA; OTC; QL
EVENCARE MINI
GLUCOSE TEST
STR
CONTOUR TEST
STRIPS
3
PA; OTC; QL
EVOLUTION TEST
STRIPS
3
PA; OTC; QL
CONTROL G3
3
PA; OTC; QL
3
PA; OTC; QL
DIATRUE PLUS
TEST STRIP
3
PA; OTC
EZ SMART PLUS
TEST
EZ SMART TEST
3
PA; OTC; QL
EASY PLUS II
TEST
3
PA; OTC
FIFTY50 TEST
STRIP
3
PA; OTC; QL
EASY STEP
3
PA; OTC
FORA D10
2
PA; OTC
EASY TALK
GLUCOSE TEST
3
PA; OTC; QL
FORA D15G
3
PA; OTC; QL
FORA D20
3
PA; OTC; QL
EASY TOUCH
TEST STRIP
3
PA; OTC; QL
FORA D40-G31
TEST STRIPS
3
PA; OTC; QL
EASY TRAK
GLUCOSE TEST
3
PA; OTC; QL
FORA G20
3
PA; OTC; QL
EASYGLUCO
PLUS
3
PA; OTC
FORA G30A
3
PA; OTC; QL
3
PA; OTC
EASYGLUCO
TEST
3
FORA GD50 TEST
STRIPS
FORA TEST STRIP
3
PA; OTC; QL
EASYMAX
3
PA; OTC; QL
3
PA; OTC
ELEMENT
COMPACT TEST
STRIPS
3
PA; OTC
FORA TN'G VOICE
TEST STRIPS
FORA V10
3
PA; OTC
3
PA; OTC
ELEMENT TEST
STRIPS
3
FORA V12
GLUCOSE
FORA V20
3
PA; OTC; QL
PA; OTC; QL
PA; OTC; QL
48
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
FORACARE GD20
3
PA; OTC; QL
3
PA; OTC
FORACARE GD40
3
PA; OTC; QL
GMATE TEST
STRIPS
FORTISCARE
GLUCOSE TEST
STRIPS
3
PA; OTC
HEALTHPRO
TEST STRIPS
3
PA; OTC
3
PA; OTC; QL
FREESTYLE
INSULINX
2
INFINITY TEST
STRIPS
LIBERTY TEST
3
PA; OTC; QL
FREESTYLE
INSULINX TEST
STRIPS
2
OTC; QL
MICRO BLOOD
GLUCOSE
3
PA; OTC
PA; OTC; QL
2
OTC; QL
MICRODOT
BLOOD GLUCOSE
SYSTEM
3
FREESTYLE LITE
STRIPS
FREESTYLE
PRECISION NEO
STRIPS
2
OTC
MYGLUCOHEALT
H
3
PA; OTC; QL
PA; OTC; QL
2
OTC; QL
NEUTEK 2TEK
TEST STRIPS
3
FREESTYLE TEST
GE100 BLOOD
GLUCOSE TEST
STRIP
3
PA; OTC; QL
NOVA MAX
GLUCOSE TEST
3
PA; OTC; QL
PA; OTC
3
PA; OTC
ON CALL
EXPRESS TEST
STRIP
3
GENSTRIP TEST
STRIP
GLUCO NAVII
TEST STRIP
3
PA; OTC
ON CALL PLUS
TEST STRIP
3
PA; OTC; QL
GLUCOCARD 01
SENSOR PLUS
3
PA; OTC
ON CALL VIVID
TEST STRIP
3
PA; OTC; QL
GLUCOCARD
EXPRESSION
3
PA; OTC; QL
ONETOUCH
ULTRA TEST
3
PA; OTC; QL
GLUCOCARD
SHINE TEST
STRIPS
3
PA; OTC
ONETOUCH
VERIO
3
PA; OTC; QL
OPTIUM EZ
2
PA; OTC; QL
GLUCOCARD
VITAL SENSOR
3
PA; OTC; QL
OPTIUM TEST
2
PA; OTC; QL
GLUCOCARD
VITAL TEST
STRIPS
3
PA; OTC; QL
OPTUMRX
3
PA; OTC
PHARMACIST
CHOICE
3
PA; OTC; QL
GLUCOCOM
GLUCOSE
3
PA; OTC; QL
PRECISION PCX
PLUS TEST
2
OTC; QL
GM100
3
PA; OTC; QL
OTC; QL
49
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
PRECISION PCX
TEST
2
OTC; QL
TRUETRACK
TEST
3
PA; OTC; QL
PRECISION POINT
OF CARE TEST
2
OTC; QL
ULTIMA TEST
STRIPS
2
PA; OTC
PRECISION Q-I-D
TEST
2
OTC; QL
ULTRATRAK
2
PA; OTC
PA; OTC; QL
2
OTC; QL
ULTRATRAK
ULTIMATE
3
PRECISION XTRA
TEST
PA; OTC
3
PA; OTC; QL
UNISTRIP1 TEST
STRIP
3
PREMIUM V10
PRODIGY NO
CODING
3
PA; OTC; QL
WAVESENSE
JAZZ
3
PA; OTC
QUINTET AC
3
PA; OTC
3
PA; OTC; QL
REFUAH PLUS
3
PA; OTC; QL
WAVESENSE
PRESTO
RELION
CONFIRM-MICRO
3
PA; OTC; QL
DIABETES, SUPPLIES, & DURABLE
MEDICAL EQUIPMENT
RELION PRIME
TEST STRIPS
3
PA; OTC; QL
GLUCAGEN
DIAGNOSTIC KIT
3
QL
REVEAL TEST
STRIP
3
PA; OTC; QL
GLUCAGON HCL
3
QL
RIGHTEST GS550
TEST STRIPS
3
PA; OTC; QL
GLUCAGEN
HYPOKIT
3
QL
SMART SENSE
TEST STRIPS
3
PA; OTC
3
QL
SMARTEST TEST
3
PA; OTC; QL
GLUCAGON
EMERGENCY KIT
(HUMAN)
SOLUS V2 TEST
STRIPS
3
PA; OTC; QL
PROGLYCEM
3
SURE-TEST
EASYPLUS MINI
3
PA; OTC; QL
INSULIN
SYRINGES/MISCELLANEOUS
DURABLE MEDICAL EQU
TELCARE TEST
STRIPS
3
PA; OTC; QL
1ST TIER UNIFINE
PENTIPS
2
OTC
TEST N'GO TEST
3
PA; OTC
2
OTC
TRUE METRIX
GLUCOSE TEST
STRIP
3
PA; OTC
1ST TIER UNILET
COMFORTOUCH
3
PA; QL
TRUETEST TEST
STRIPS
3
ACCU-CHEK
AVIVA CONNECT
METER
GLUCOSE ELEVATING AGENTS
PA; OTC
50
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
ACCU-CHEK
AVIVA PLUS
METER
3
OTC; QL
ADVOCATE REDICODE GLU
MONITOR
3
OTC
ACCU-CHEK
COMBO SYSTEM
3
QL
3
OTC
ACCU-CHEK
FASTCLIX
3
OTC
AGAMATRIX
AMP GLUC
MONITOR SYS
2
OTC
ACCU-CHEK
NANO
3
ALTERNATE SITE
LANCET
3
OTC
ACCU-CHEK
SAFE-T-PRO
3
ALTERNATE SITE
LANCING DEVICE
3
OTC
ACCU-CHEK
SOFTCLIX
LANCET DEV
3
AQUA LANCE
LANCING DEVICE
ASSURE LANCE
2
OTC
3
OTC
ACCU-CHEK
SOFTCLIX
LANCETS
3
ASSURE LANCE
PLUS
ASSURE
PLATINUM
3
OTC
ACTI-LANCE
LANCETS
2
OTC
ASSURE PRISM
MULTI METER
3
OTC
ADJUSTABLE
LANCING DEVICE
3
OTC
3
OTC
ADVANCED
GLUCOSE METER
3
OTC
AUTOJECT 2
INJECTION
DEVICE
OTC
3
OTC
AUTO-LANCET
MINI
3
ADVANCED
LANCING DEVICE
OTC
2
OTC
AUTOLET
IMPRESSION
LANC DEV
3
ADVANCED
TRAVEL
LANCETS
OTC
3
OTC
AUTOLET
LANCING DEVICE
3
ADVOCATE
BLOOD GLUCOSE
MONITOR
AUTOPEN 2 TO 32
UNITS
3
OTC
ADVOCATE
LANCET
2
OTC
BD AUTOSHIELD
PEN NEEDLE
2
OTC
ADVOCATE PEN
NEEDLES
2
OTC
3
ADVOCATE
RAPID-SAFE
LANCING
3
OTC; QL
BD CURVED
TONSIL
REUSABLE
BD ECLIPSE
3
OTC; QL
OTC
OTC; QL
OTC
51
Drug Name
Drug
Tier
BD FILTER
NEEDLE-5
MICRON
3
BD INSULIN PEN
NEEDLE UF
SHORT
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
BLOOD-GLUCOSE
METER
3
3
2
BLUNT NEEDLE,
DISPOSABLE
2
OTC
BD INTEGRA
NEEDLE
3
BULLSEYE MINI
SAFETY
LANCETS
OTC
3
OTC
CAREFINE PEN
NEEDLE
3
BD LANCET
DEVICE
2
OTC
BD
MICROTAINER
LANCET
2
OTC
CAREONE THIN
LANCET
CARESENS N
3
OTC
BD NOKOR
ADMIX NEEDLE
3
CARESENS N
VOICE
3
OTC
BD
PRECISIONGLIDE
3
CLEVER CHEK
BLOOD GLUCOSE
3
OTC
BD
PRECISIONGLIDE
NON-STERILE
3
CLEVER CHEK
LANCETS
2
OTC
3
OTC
BD QUINCKE
SPINAL NEEDLE
3
CLEVER CHOICE
GLUCOSE
MONITOR
BD SAFETYGLIDE
NEEDLE
3
CLEVER CHOICE
MICRO
3
OTC
BD SPECIALTY
USE NEEDLES
3
CLEVER CHOICE
PRO
3
OTC
BD ULTRA FINE
LANCETS
2
CLICKFINE
2
OTC
2
OTC
BD ULTRA-FINE
NANO PEN
NEEDLES
2
COAGUCHEK
LANCETS
COLOR LANCETS
2
OTC
2
OTC
BD WHITACRE
SPINAL NEEDLE
3
COMFORT EZ PEN
NEEDLES
OTC
3
COMFORT
LANCETS
2
BD YALE
REUSABLE REG
METAL
CONTOUR LINK
3
OTC
BIONIME
RIGHTEST GM300
SYSTEM
3
CONTOUR NEXT
EZ METER
3
OTC
OTC
OTC
OTC
OTC
52
OTC
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
EASY TOUCH
HYPODERMIC
NEEDLE
3
EASY TOUCH
LANCING DEVICE
3
OTC
EASY TRAK
BLOOD GLUCOSE
METER
3
OTC
EASYGLUCO
MONITORING
SYSTEM
3
OTC
EASYMAX L
BLOOD GLUCOSE
METER
3
OTC
EASYMAX NG
3
OTC
EASYMAX V
SPEAKING
GLUCOSE SYS
3
OTC
EASYMAX V2
BLOOD GLUCOSE
METER
3
OTC
ELEMENT
COMPACT
GLUCOSE METER
3
OTC
3
OTC
OTC
ELEMENT
COMPACT V
GLUCOSE MTR
3
OTC
CONTOUR NEXT
METER
3
OTC
CONTOUR NEXT
USB METER
3
OTC
CONTROL
MONITORING
SYSTEM
3
DIATRUE PLUS
BLOOD GLUCOSE
MET
3
DROPLET
LANCETS
2
DROPLET
LANCING DEVICE
3
OTC
DROPLET PEN
NEEDLE
2
OTC
EASY CLICK
LANCING DEVICE
3
OTC
EASY COMFORT
LANCETS
2
OTC
EASY COMFORT
PEN NEEDLES
2
OTC
EASY MINI EJECT
LANCING DEVICE
3
OTC; QL
EASY PLUS II
BLOOD GLUCOSE
MET
3
EASY STEP
BLOOD GLUCOSE
METER
3
OTC
ELEMENT PLUS
BLOOD GLUCOSE
KIT
OTC
3
OTC
EMBRACE
BLOOD GLUCOSE
SYSTEM
3
EASY TALK
BLOOD GLUCOSE
METER
OTC
3
EMBRACE PRO
GLUCOSE METER
3
EASY TOUCH
FLIPLOCK
NEEDLE
ENLITE SYSTEM
3
EASY TOUCH
GLUCOSE
MONITOR
3
EVENCARE G2
3
OTC
EVENCARE G3
GLUCOSE METER
3
OTC
OTC
OTC
OTC
OTC
53
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
OTC
FORA V12 BLOOD
GLUCOSE
SYSTEM
3
OTC
FORA V20
3
OTC
FORA V30A
3
OTC
FORACARE GD20
GLUCOSE METER
3
OTC
FORACARE
GD40A GLUCOSE
METER
3
OTC
FORACARE
GD40B GLUCOSE
METER
3
OTC
EVOLUTION
BLOOD GLUCOSE
METER
3
EXEL
HYPODERMIC
NEEDLES
3
e-z ject lancets
1
OTC
EZ SMART
LANCETS
2
OTC
EZ SMART PLUS
SYSTEM
3
OTC
EZ SMART
SYSTEM
3
OTC
FIFTY50 SAFETY
SEAL LANCETS
2
OTC
FORACARE
LANCETS
2
OTC
FINE 30
UNIVERSAL
LANCETS
2
OTC
FORTISCARE
BLOOD GLUCOSE
SYST
3
OTC
FINGERSTIX
LANCETS
2
OTC
FREESTYLE
FLASH SYSTEM
0
OTC
FIRST CHOICE
LANCETS THIN
2
OTC
FREESTYLE
FREEDOM
0
OTC
FLOW-EZE
VENTED NEEDLE
3
FREESTYLE
FREEDOM LITE
0
OTC
FORA D20
3
OTC
0
OTC
FORA G20
3
OTC
FREESTYLE
INSULINX
FORA G30A
3
OTC
FREESTYLE
LANCETS
2
OTC
FORA GD50
BLOOD GLUCOSE
SYSTEM
3
OTC
FREESTYLE LITE
METER
0
OTC
FORA LANCING
DEVICE
3
OTC
FREESTYLE
PRECISION NEO
METER
0
OTC
FORA TEST N'GO
VOICE METER
3
OTC
FREESTYLE
SIDEKICK II
0
OTC
FORA TN'G VOICE
METER
3
OTC
FREESTYLE
SYSTEM KIT
0
OTC
FORA V10
3
OTC
54
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
FREESTYLE
UNISTIK 2
2
OTC
2
OTC
GE100 BLOOD
GLUCOSE
SYSTEM
3
OTC
HEALTHY
ACCENTS
UNIFINE PENTIP
2
OTC
GLUCO NAVII
GLUCOSE
MONITOR
3
HEALTHY
ACCENTS UNILET
LANCET
huber safety needles
(disp.)
1
GLUCOCARD 01
METER
3
OTC
HUMAPEN
LUXURA HD
3
GLUCOCARD
EXPRESSION
3
OTC
HYPOLANCE AST
LANCING
3
OTC
GLUCOCARD
SHINE METER
3
OTC
INCONTROL
LANCING DEVICE
3
OTC
GLUCOCARD
VITAL
3
OTC
INCONTROL PEN
NEEDLE
2
OTC
GLUCOCOM
BLOOD GLUCOSE
3
OTC
2
OTC
GLUCOCOM
LANCETS
2
OTC
INCONTROL
SUPER THIN
LANCETS
2
OTC
GM100
3
OTC
INCONTROL
ULTRA THIN
LANCETS
GMATE LANCETS
3
OTC
3
OTC
GMATE LANCING
DEVICE
3
OTC; QL
INFINITY
STARTER KIT
OTC
3
OTC
INJECT EASE
LANCETS
2
GMATE SMART
METER
INSUPEN
2
OTC
GMATE SMART
STARTER
3
OTC
INVACARE
LANCETS
2
OTC
GMATE VOICE
METER
3
OTC
KINNEY BRAND
LANCETS
2
OTC
HEALTHPRO
GLUCOSE
MONITOR
3
OTC
LANCETS
2
OTC
3
OTC
HEALTHY
ACCENTS
AUTOLET
3
LANCETS 30
GAUGE
LANCETS,THIN
2
OTC
LANCING DEVICE
WITH LANCETS
3
OTC
OTC
OTC
55
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
LANCING
SYSTEM
3
OTC; QL
MULTI-LANCET
DEVICE 2
3
OTC
LANZO LANCING
DEVICE
3
OTC
MYGLUCOHEALT
H
3
OTC
LIFESHIELD
BLUNT CANNULA
3
MYGLUCOHEALT
H LANCETS
2
OTC
LITE TOUCH
LANCETS
2
NEEDLES, HUBER
DISPOSABLE
3
LOCAL
ANESTHESIA
NEEDLE 22GX2"
3
NOKOR NEEDLE
3
3
OTC
MEDISENSE THIN
LANCETS
2
OTC
NOVA MAX
BLOOD GLUCOSE
METER
OTC
3
OTC
NOVA SAFETY
LANCETS
2
MEDLANCE PLUS
LANCETS
OTC
2
OTC
NOVA SUREFLEX
LANCETS
2
MICRO THIN
LANCETS
NOVOFINE 32
2
OTC
MICRODOT
BLOOD GLUCOSE
SYSTEM
3
OTC
NOVOFINE
AUTOCOVER
2
OTC
MICROLET
LANCET
2
OTC
NOVOFINE PLUS
2
OTC
NOVOPEN ECHO
3
MINI LANCING
DEVICE
3
OTC
NOVOTWIST
2
OTC
3
OTC
MINI ULTRATHIN II
2
OTC
ON CALL
EXPRESS METER
ON CALL LANCET
2
OTC
MONOJECT
BLOOD
COLLECTION
3
ON CALL
LANCING DEVICE
3
OTC
MONOJECT
HYPODERMIC
NEEDLES
3
ON CALL PLUS
LANCET
2
OTC
3
OTC
MONOJECT
MEDICATION
TRANSF NDL
3
ON CALL PLUS
LANCING DEVICE
ON CALL PLUS
METER
3
OTC
MONOLET THIN
LANCETS
2
ON CALL VIVID
METER
3
OTC
MULTI-DRAW
NEEDLE
3
ON CALL VIVID
PAL METER
3
OTC
OTC
OTC
56
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
OTC
POLY HUB
NEEDLE
3
0
OTC
OTC
PRECISION XTRA
MONITOR
PREMIUM BLOOD
GLUCOSE
MONITOR
3
OTC
PREMIUM V10
3
OTC
2
OTC
ONETOUCH
DELICA LANC
DEVICE
3
ONETOUCH
SURESOFT
LANCING DEV
3
ONETOUCH
ULTRA2
3
OTC
ONETOUCH
ULTRAMINI
3
OTC
ONETOUCH
ULTRASOFT
LANCETS
2
OTC
PRESSURE
ACTIVATED
LANCETS
3
OTC
ONETOUCH
VERIO FLEX
3
OTC
PRESTO PRO
BLOOD GLUCOSE
METER
OTC
3
OTC
PRODIGY
AUTOCODE
METER
3
ONETOUCH
VERIO IQ METER
ONETOUCH
VERIO SYNC
3
OTC
3
OTC
ONETOUCH
VERIO SYSTEM
3
OTC
PRODIGY
AUTOCODE
MONITOR SYST
2
OTC
ON-THE-GO
LANCETS
2
PRODIGY
LANCETS
3
OTC
OPTUMRX
3
PRODIGY
LANCING DEVICE
PARASYMPATH
NERVE NDL 20 G
X6"
3
PRODIGY
POCKET METER
3
OTC
2
OTC
PEN NEEDLE
2
OTC
PRODIGY TWIST
TOP LANCET
PEN NEEDLE,
DIABETIC
2
OTC
PRODIGY VOICE
GLUCOSE METER
3
OTC
PENTIPS
3
OTC
QUINTET BLOOD
GLUCOSE METER
3
OTC
PENTIPS PEN
NEEDLE
2
OTC
3
OTC; QL
PHARMACIST
CHOICE
GLUCOSE SYS
3
OTC
REFUAH PLUS
GLUCOSE
MONITOR
RELIAMED
LANCET
2
OTC
PHASEAL
PROTECTOR
3
RELIAMED MINI
LANCING DEVICE
3
OTC
OTC
OTC
57
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
OTC
SMARTDIABETES
VANTAGE
3
OTC
SMARTEST EJECT
3
OTC
2
OTC
RELIAMED
SAFETY SEAL
LANCETS
2
RELION CONFIRM
3
OTC
RELION MICRO
GLUCOSE
MONITOR
3
OTC
SMARTEST
LANCET
3
OTC
RELION NEEDLES
2
OTC
SMARTEST
PERSONA
STARTER
RELION PEN
NEEDLES
2
OTC
3
OTC
RELION PRIME
METER
3
OTC
SMARTEST
PRONTO
STARTER
3
OTC
RELION THIN
LANCETS
2
SMARTEST
PROTEGE
3
RELION ULTRA
THIN PLUS
LANCETS
2
SNAP INSULIN
PUMP
CONTROLLER
3
REVEAL BLOOD
GLUCOSE METER
3
OTC
SNAP INSULIN
PUMP-INFUSION
SET
RIGHTEST GD500
LANCING DEVICE
3
OTC
SOFT TOUCH
LANCETS
2
OTC
RIGHTEST GL300
LANCETS
2
OTC
SOLUS V2
AUDIBLE METER
3
OTC
RIGHTEST GM550
SYSTEM
3
OTC
SOLUS V2
LANCETS
2
OTC
SAFETY
LANCETS
2
OTC
SOLUS V2
LANCING DEVICE
3
OTC
SAFETY SEAL
LANCETS
2
OTC
STERILANCE TL
2
OTC
2
OTC
SAFETY-LET
LANCETS
2
SUPER THIN
LANCETS
2
OTC
SINGLE-LET
2
OTC
SURE COMFORT
LANCETS
SMART SENSE
LANCETS
2
OTC
SURE COMFORT
LANCING PEN
3
OTC
SMART SENSE
MONITORING
SYSTEM
3
OTC
SURE COMFORT
PEN NEEDLE
2
OTC
SURE-FINE PEN
NEEDLES
2
OTC
OTC
OTC
OTC
58
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
TRUERESULT
BLOOD GLUCOSE
SYSTM
3
OTC
TRUETRACK
BLOOD GLUCOSE
SYSTEM
3
OTC
TRUETRACK
SMART SYSTEM
3
OTC
ULTICARE PEN
NEEDLE
2
OTC
ULTI-LANCE
3
OTC
ULTILET BASIC
LANCETS
2
OTC
ULTILET CLASSIC
LANCETS
2
OTC
ULTILET
LANCETS
2
OTC
ULTILET PEN
NEEDLE
2
OTC
SUREFLEX
LANCING DEVICE
3
OTC
SURE-LANCE
2
OTC
SURE-PEN
LANCING DEVICE
3
OTC
SURE-TEST
EASYPLUS MINI
METER
3
OTC
SURE-TOUCH
LANCET
2
OTC
SURGUARD2
SAFETY
3
T:SLIM
3
T:SLIM G4
3
TECHLITE
LANCETS
2
OTC
TECHLITE PEN
NEEDLE
2
OTC
TELCARE BGM
3
OTC
OTC
3
OTC
ULTILET SAFETY
LANCETS
2
TELCARE BLOOD
GLUCOSE KIT
OTC
3
OTC
ULTIMA
MONITOR
0
TEST N'GO
BLOOD GLUCOSE
SYSTEM
ULTRA THIN
LANCETS
2
OTC
TITUS NEEDLE
3
OTC
2
ULTRA THIN
PLUS LANCETS
2
TOPCARE
UNIVERSAL1
LANCET
ULTRA TLC
LANCETS
2
OTC
TRUE METRIX
GLUCOSE METER
3
OTC
ULTRALANCE
LANCETS
2
OTC
TRUE2GO BLOOD
GLUCOSE
SYSTEM
3
OTC
ULTRA-THIN II
INS PEN NEEDLES
2
OTC
TRUEDRAW
LANCING DEVICE
3
OTC
ULTRATRAK
GLUCOSE METER
3
OTC
TRUEPLUS
LANCETS
2
OTC
ULTRATRAK
ULTIMATE
3
OTC
UNIFINE PENTIPS
2
OTC
OTC
59
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
UNIFINE PENTIPS
PLUS
2
OTC
YALE SPINAL
NEEDLE
UNILET
COMFORTOUCH
LANCET
2
OTC
INSULIN THERAPY
UNILET
EXCELITE II
LANCET
2
UNILET
EXCELITE
LANCET
2
UNILET GP
LANCET
2
OTC
UNILET LANCET
2
OTC
UNISTIK 2
DEVICE
3
UNISTIK 2
NORMAL
LANCET,DEVICE
3
UNISTIK 3
3
OTC
UNISTIK 3 EXTRA
LANCET
2
OTC
UNISTIK CZT
LANCET
2
OTC
UNISTIK SAFETY
3
OTC
UNISTIK TOUCH
LANCETS
3
OTC
UNIVERSAL 1
LANCETS
2
OTC
VGO 20
3
VGO 30
Drug
Tier
Requirements
/ Limits
3
OTC
AFREZZA
3
PA
APIDRA
3
PA
APIDRA
SOLOSTAR
3
PA
HUMALOG
2
HUMALOG
KWIKPEN
2
HUMALOG MIX
50-50
2
HUMALOG MIX
50-50 KWIKPEN
2
OTC
HUMALOG MIX
75-25
2
OTC
HUMALOG MIX
75-25 KWIKPEN
2
HUMULIN 70/30
2
HUMULIN 70/30
KWIKPEN
2
HUMULIN N
2
HUMULIN N
KWIKPEN
2
HUMULIN R
2
HUMULIN R U-500
(CONC) KWIKPEN
2
2
3
HUMULIN R U-500
(CONCENTRATED
)
VGO 40
3
LANTUS
2
WAVESENSE AMP
3
OTC
2
WAVESENSE
JAZZ
3
OTC
LANTUS
SOLOSTAR
LEVEMIR
2
WAVESENSE
PRESTO
3
LEVEMIR
FLEXTOUCH
2
OTC
OTC
OTC
60
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
NOVOLIN 70/30
3
PA
calcitriol oral
1
NOVOLIN N
3
PA
CERDELGA
4
PA
NOVOLIN R
3
PA
CEREZYME
4
PA
NOVOLOG
3
PA
CETROTIDE
4
PA; LA
NOVOLOG
FLEXPEN
3
PA
4
NOVOLOG MIX
70-30
3
PA
chorionic
gonadotropin,
human
clomiphene citrate
1
NOVOLOG MIX
70-30 FLEXPEN
3
danazol
1
DDAVP
3
NOVOLOG
PENFILL
3
DEPOTESTOSTERONE
3
TOUJEO
SOLOSTAR
2
desmopressin
1
TRESIBA
FLEXTOUCH U100
3
doxercalciferol
intravenous
1
doxercalciferol oral
1
TRESIBA
FLEXTOUCH U200
3
ELAPRASE
4
PA; LA
ELELYSO
4
PA
FABRAZYME
4
PA; LA
FOLLISTIM AQ
4
PA; LA
FORTESTA
3
PA
fortical
1
GANIRELIX
4
PA; LA
GONAL-F
4
PA; LA
GONAL-F RFF
4
PA; LA
GONAL-F RFF
REDI-JECT
4
PA; LA
3
PA
PA
PA
ST
ST
MISCELLANEOUS HORMONES
PA
ACTHREL
3
PA
ALDURAZYME
4
PA; LA
ANADROL-50
3
PA
ANDRODERM
3
PA; QL
ANDROGEL
3
PA; QL
ANDROID
3
PA; QL
androxy
1
PA; QL
AVEED
4
PA
AXIRON
3
PA
HECTOROL
INTRAVENOUS
BRAVELLE
4
PA; LA
HECTOROL ORAL
3
cabergoline
1
KORLYM
4
PA
calcitonin (salmon)
1
KUVAN
4
PA; LA
calcitriol
intravenous
1
LUMIZYME
4
PA; LA
MENOPUR
4
PA; LA
PA
61
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
METHITEST
3
PA; QL
1
methyltestosterone
1
PA; QL
testosterone
cypionate
MIACALCIN
INJECTION
3
PA
testosterone
enanthate
1
MIACALCIN
NASAL
3
1
PA; QL
MYALEPT
4
PA; LA
MYOZYME
4
PA; LA
testosterone
transdermal gel in
metered-dose pump
1.25 gram/ actuation
(1 %)
NAGLAZYME
4
PA; LA
3
PA
NATESTO
3
PA
NATPARA
4
PA; LA
novarel
4
OVIDREL
4
TESTOSTERONE
TRANSDERMAL
GEL IN
METERED-DOSE
PUMP 10 MG/0.5
GRAM
/ACTUATION
OXANDRIN
3
PA
1
PA; QL
oxandrolone
1
PA
testosterone
transdermal gel in
packet
pamidronate
4
PA; LA
TESTRED
3
PA; QL
PARICALCITOL
HEMODIALYSIS
PORT INJECTION
3
PA
VASOSTRICT
3
PA
VIMIZIM
4
PA; LA
paricalcitol oral
1
VOGELXO
3
PA; QL
PREGNYL
4
VPRIV
4
PA; LA
ROCALTROL
3
ZAVESCA
4
PA; LA
SAMSCA
4
3
PA
SENSIPAR
3
ZEMPLAR
INTRAVENOUS
SOMAVERT
4
ZEMPLAR ORAL
3
STIMATE
4
zoledronic acid
4
PA
STRENSIQ
4
PA
4
LA
STRIANT
3
PA; QL
ZOLEDRONIC
ACID-MANNITOLWATER
SYNAREL
2
PA
ZOMETA
4
PA; LA
TESTIM
2
PA; QL
TESTONE CIK
3
NON-INSULIN HYPOGLYCEMIC
AGENTS
TESTOPEL
4
QL
PA; LA
PA; LA
PA; LA
acarbose
1
ACTOPLUS MET
3
62
Requirements
/ Limits
QL
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
JARDIANCE
2
ST
JENTADUETO
2
ST
JENTADUETO XR
2
ST
KAZANO
2
ST
KOMBIGLYZE XR
3
PA
metformin oral
tablet
1
metformin oral
tablet extended
release 24 hr
1
metformin oral
tablet extended
release 24hr
1
PA
1
PA
ACTOPLUS MET
XR
3
ST; QL
ACTOS
3
QL
AMARYL
3
AVANDIA
3
PA; ST; QL
BYDUREON
2
ST; QL
BYETTA
2
ST; QL
chlorpropamide
1
CYCLOSET
3
DUETACT
3
FARXIGA
3
ST
FORTAMET
3
PA
glimepiride
1
glipizide
1
metformin oral
tablet,er
gast.retention 24 hr
glipizide-metformin
1
miglitol
1
GLUCOPHAGE
3
nateglinide
1
GLUCOPHAGE XR
3
NESINA
2
ST
GLUCOTROL
3
ONGLYZA
3
PA
GLUCOTROL XL
3
OSENI
2
ST
GLUCOVANCE
3
pioglitazone
1
QL
glyburide
1
1
glyburide
micronized
1
pioglitazoneglimepiride
1
glyburide-metformin
1
pioglitazonemetformin
GLYNASE
3
PRANDIN
3
GLYSET
3
PRECOSE
3
GLYXAMBI
3
PA
repaglinide
1
INVOKAMET
2
ST
repaglinidemetformin
1
INVOKANA
2
ST
RIOMET
3
JANUMET
3
PA
STARLIX
3
JANUMET XR
3
PA
SYMLINPEN 120
3
ST; QL
JANUVIA
3
PA
SYMLINPEN 60
3
ST; QL
63
QL
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
SYNJARDY
2
ST
GASTROENTEROLOGY
TANZEUM
3
PA
tolazamide
1
ANTIDIARRHEALS &
ANTISPASMODICS
tolbutamide
1
anaspaz
1
TRADJENTA
2
ST
atropine
1
TRULICITY
3
PA
1
VICTOZA 2-PAK
2
ST; QL
belladonna
alkaloids-opium
VICTOZA 3-PAK
2
PA; QL
belladonna-opium
1
XIGDUO XR
3
ST
BENTYL
INTRAMUSCULA
R
3
THYROID HORMONES
Drug
Tier
Requirements
/ Limits
PA
PA
ARMOUR
THYROID
2
BENTYL ORAL
3
3
chlordiazepoxideclidinium
1
CYTOMEL
levothyroxine
intravenous
1
CUVPOSA
4
PA; LA
1
PA
levothyroxine oral
1
dicyclomine
intramuscular
levoxyl
1
dicyclomine oral
1
liothyronine
intravenous
1
diphenoxylateatropine
1
liothyronine oral
1
DONNATAL
3
nature-throid
1
ed-spaz
1
np thyroid
1
FULYZAQ
3
QL
SYNTHROID
3
1
PA
THYROLAR-1
2
glycopyrrolate
injection
THYROLAR-1/2
2
glycopyrrolate oral
1
THYROLAR-1/4
2
hyoscyamine sulfate
1
THYROLAR-2
2
hyosyne
1
THYROLAR-3
2
LEVBID
3
TIROSINT
3
LEVSIN
INJECTION
3
TRIOSTAT
3
LEVSIN ORAL
3
unithroid
1
LEVSIN/SL
3
westhroid
1
3
WP THYROID
3
LIBRAX (WITH
CLIDINIUM)
PA
PA
PA
64
PA
Drug Name
Drug
Tier
LOMOTIL
Requirements
/ Limits
Drug Name
Drug
Tier
3
anucort-hc
1
loperamide
1
ANUSOL-HC
3
methscopolamine
1
3
PA
MOTOFEN
3
ANZEMET
INTRAVENOUS
NULEV
3
ANZEMET ORAL
3
ST; QL
opium tincture
1
APRISO
2
oscimin
1
ASACOL HD
3
oscimin sl
1
AURYXIA
3
oscimin sr
1
AZULFIDINE
3
paregoric
1
AZULFIDINE ENTABS
3
phenohytro
1
balsalazide
1
propantheline
1
bisacodyl
0
ROBINUL FORTE
3
budesonide
1
ROBINUL
INJECTION
3
calcium acetate
1
ROBINUL ORAL
3
CANASA
2
SYMAX DUOTAB
3
CESAMET
3
symax fastabs
1
CHENODAL
4
symax-sl
1
CHOLBAM
4
symax-sr
1
CIMZIA
4
PA; LA; QL
CIMZIA POWDER
FOR RECONST
4
PA; LA; QL
citrate of magnesia
0
ACA; OTC
COLAZAL
3
colocort
1
PA
MISCELLANEOUS
GASTROINTESTINAL AGENTS
ACTIGALL
3
AKYNZEO
3
PA; LA; QL
alosetron
1
QL
ALOXI
3
PA
COLYTE WITH
FLAVOR PACKS
3
AMITIZA
2
QL
COMPAZINE
3
ANA-LEX KIT
3
compro
1
ANALPRAM E
3
constulose
1
ANALPRAM-HC
3
CORTENEMA
3
ANALPRAM-HC
SINGLES
3
CORTIFOAM
2
CREON
2
ANTIVERT
3
65
Requirements
/ Limits
PA
ACA; OTC
PA
Drug Name
Drug
Tier
Requirements
/ Limits
cromolyn
1
CYSTADANE
4
DICLEGIS
3
QL
dimenhydrinate
1
PA
DIPENTUM
3
PA
dronabinol
1
droperidol
1
eliphos
1
EMEND
INTRAVENOUS
3
PA
EMEND ORAL
CAPSULE 125 MG
3
QL
EMEND ORAL
CAPSULE 40 MG,
80 MG
3
EMEND ORAL
CAPSULE,DOSE
PACK
3
ENTOCORT EC
3
ENTYVIO
4
enulose
1
FOSRENOL
3
GASTROCROM
3
GATTEX 30-VIAL
4
PA; LA
gavilyte-c
0
ACA
gavilyte-g
0
ACA
gavilyte-h and
bisacodyl
0
ACA
gavilyte-n
0
ACA
generlac
Drug Name
Drug
Tier
Requirements
/ Limits
granisetron hcl
intravenous
1
PA
granisetron hcl oral
1
ST; QL
hemmorex-hc
1
hydrocortisone
1
hydrocortisone
acetate
1
hydrocortisonepramoxine
1
KAYEXALATE
3
KINEVAC
3
kionex
1
KRISTALOSE
3
lactulose
1
laxative peg 3350
0
ACA; OTC
LIALDA
3
PA
rectal cream
1
LIDOCAINE HCLHYDROCORTISO
N AC RECTAL
GEL
3
rectal kit
1
lidocainehydrocortisone-aloe
1
LINZESS
2
QL
LOTRONEX
3
QL
1
MAGNEBIND 400
3
GIAZO
3
MARINOL
3
GOLYTELY
3
meclizine
1
granisetron (pf)
1
mesalamine
1
PA
QL
PA; LA
PA
66
PA
Drug Name
Drug
Tier
Requirements
/ Limits
mesalamine with
cleansing wipe
1
metoclopramide hcl
injection
1
metoclopramide hcl
oral
1
METOZOLV ODT
3
milk of magnesia
concentrated
0
MOVANTIK
3
MOVIPREP
3
NOVACORT
3
NULYTELY WITH
FLAVOR PACKS
3
OCALIVA
4
ondansetron
1
ondansetron hcl (pf)
1
PA
ondansetron hcl
intravenous
1
PA
ondansetron hcl oral
solution
1
tablet 24 mg
1
tablet 4 mg, 8 mg
1
OSMOPREP
Drug Name
Drug
Tier
Requirements
/ Limits
PHOSLO
3
PHOSLYRA
3
phosphate laxative
0
ACA; OTC
polyethylene glycol
3350
0
ACA
pramcort
1
PREPOPIK
3
prochlorperazine
1
prochlorperazine
edisylate
1
prochlorperazine
maleate
1
PROCORT
3
PROCTOCORT
3
PROCTOFOAM HC
3
procto-med hc
1
procto-pak
1
proctosol hc
1
proctozone-hc
1
RECTIV
3
REGLAN
3
RELISTOR
3
PA
REMICADE
4
PA; LA
3
RENAGEL
2
QL
PANCREAZE
3
RENVELA
2
peg 3350electrolytes
0
ROWASA
3
SANCUSO
3
peg-3350 with flavor
packs
0
ACA
sodium polystyrene
sulfonate oral
1
peg-electrolyte soln
0
ACA
0
ACA
PENTASA
3
PA
sodium polystyrene
sulfonate rectal
enema 30 gram/120
ml
1
peg-prep
PERTZYE
3
PA
ACA; OTC
PA
PA; LA
QL
ACA
67
PA
ST; QL
Drug Name
Drug
Tier
SODIUM
POLYSTYRENE
SULFONATE
RECTAL ENEMA
50 GRAM/200 ML
3
sps
1
SUCRAID
4
sulfasalazine
1
SUPREP BOWEL
PREP KIT
3
TIGAN
INTRAMUSCULA
R
3
TIGAN ORAL
3
TRANSDERMSCOP
3
trilyte with flavor
packets
0
trimethobenzamide
1
UCERIS
3
URSO 250
3
URSO FORTE
3
ursodiol
1
VARUBI
3
VELPHORO
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
ZENPEP ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
10,000-34,000 55,000 UNIT,
15,000-51,000 82,000 UNIT,
20,000-68,000 109,000 UNIT,
25,000-85,000136,000 UNIT,
3,000-10,00016,000 UNIT
2
ZENPEP ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
40,000-136,000218,000 UNIT,
5,000-17,000 27,000 UNIT
3
ZOFRAN (AS
HYDROCHLORID
E) INTRAVENOUS
3
ZOFRAN (AS
HYDROCHLORID
E) ORAL
3
QL
ZOFRAN ODT
3
3
PA
ZUPLENZ
3
PA; QL
VELTASSA
4
PA
ULCER THERAPY
VIBERZI
2
ACIPHEX
3
PA; QL
VIOKACE
3
ACIPHEX
SPRINKLE
3
PA; QL
amoxicilclarithromylansopraz
1
carafate oral
suspension
1
CARAFATE ORAL
TABLET
3
PA; LA
PA
ACA
68
PA
Drug Name
Drug
Tier
Requirements
/ Limits
cimetidine
1
cimetidine hcl
1
CYTOTEC
3
DEXILANT
3
PA
esomeprazole
magnesium
1
PA; QL
esomeprazole
sodium
1
PA
famotidine (pf)
1
PA
famotidine (pf)-nacl
(iso-os)
1
PA
famotidine
intravenous
1
famotidine oral
1
heartburn treatment
24 hour
1
OTC; QL
lansoprazole oral
capsule,delayed
release(dr/ec) 15 mg
1
QL
lansoprazole oral
capsule,delayed
release(dr/ec) 30 mg
1
misoprostol
1
NEXIUM 24HR
1
OTC
NEXIUM PACKET
3
PA
nizatidine
1
OMECLAMOXPAK
3
omeprazole
magnesium
1
omeprazole oral
capsule,delayed
release(dr/ec)
1
omeprazole oral
tablet,delayed
release (dr/ec)
1
PA
OTC
OTC
Drug Name
Drug
Tier
Requirements
/ Limits
omeprazole-sodium
bicarbonate
1
pantoprazole
intravenous
1
pantoprazole oral
1
PEPCID
3
PREVACID 24HR
3
PREVACID
SOLUTAB
3
PREVPAC
3
PRILOSEC
3
PRILOSEC OTC
3
OTC
PROTONIX
INTRAVENOUS
3
PA
PROTONIX ORAL
GRANULES DR
FOR SUSP IN
PACKET
3
PA
PROTONIX ORAL
TABLET,DELAYE
D RELEASE
(DR/EC)
3
PYLERA
2
rabeprazole
1
ranitidine hcl
1
sucralfate
1
ZANTAC
INJECTION
3
ZANTAC ORAL
3
ZEGERID ORAL
CAPSULE
3
ZEGERID ORAL
PACKET
3
PA
ZEGERID OTC
3
OTC; QL
PA
OTC; QL
QL
PA
IMMUNOLOGY, VACCINES &
BIOTECHNOLOGY
69
Drug Name
Drug
Tier
Requirements
/ Limits
BIOTECHNOLOGY DRUGS
PA; QL
Drug Name
Drug
Tier
Requirements
/ Limits
AVONEX (WITH
ALBUMIN)
4
PA; LA; QL
BETASERON
4
PA; LA
COPAXONE
SUBCUTANEOUS
SYRINGE 20
MG/ML
4
PA; LA; QL
4
PA; LA
ARANESP (IN
POLYSORBATE)
4
EPOGEN
4
PA; QL
GRANIX
4
QL
LEUKINE
4
PA
MIRCERA
4
PA
MOZOBIL
4
PA; LA
NEULASTA
4
PA; QL
COPAXONE
SUBCUTANEOUS
SYRINGE 40
MG/ML
NEUPOGEN
4
PA; QL
COPEGUS
4
LA
PROCRIT
4
PA; QL
4
PA; LA
ZARXIO
4
QL
EXTAVIA
SUBCUTANEOUS
KIT
EXTAVIA
SUBCUTANEOUS
RECON SOLN
4
LA
GILENYA
4
PA; LA
glatopa
4
PA; LA; QL
PA
GROWTH HORMONES
EGRIFTA
4
PA
GENOTROPIN
4
PA; LA
GENOTROPIN
MINIQUICK
4
PA; LA
HUMATROPE
4
PA; LA
LEMTRADA
4
NORDITROPIN
FLEXPRO
4
PA; LA
moderiba
4
moderiba dose pack
4
NUTROPIN AQ
4
PA; LA
PEGASYS
4
PA; LA
NUTROPIN AQ
NUSPIN
4
PA; LA
PEGASYS
PROCLICK
4
PA; LA
OMNITROPE
4
PA; LA
PEGINTRON
4
PA; LA; QL
SAIZEN
4
PA; LA
4
PA; LA
SAIZEN
CLICK.EASY
4
PA; LA
PEGINTRON
REDIPEN
PLEGRIDY
4
PA; LA
SEROSTIM
4
PA; LA
POMALYST
4
LA; QL
ZOMACTON
4
PA; LA
REBETOL
4
LA
ZORBTIVE
4
PA; LA
REBIF (WITH
ALBUMIN)
4
PA; LA
AUBAGIO
4
PA; LA; QL
REBIF REBIDOSE
4
PA; LA
AVONEX
4
PA; LA
INTERFERONS
70
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
ADACEL(TDAP
ADOLESN/ADULT
)(PF)
0
ACA
ATGAM
4
PA; LA
BCG VACCINE,
LIVE (PF)
0
PA; ACA; LA
BEXSERO (PF)
0
ACA
BIVIGAM
4
PA; LA
BOOSTRIX TDAP
0
ACA
CARIMUNE NF
NANOFILTERED
4
PA; LA
CERVARIX
VACCINE (PF)
0
ACA
DAPTACEL (DTAP
PEDIATRIC) (PF)
0
ACA
DYSPORT
4
PA; LA
ENGERIX-B (PF)
0
ACA
ENGERIX-B
PEDIATRIC (PF)
0
ACA
FLEBOGAMMA
DIF
4
PA; LA
FLUARIX QUAD
2016-2017 (PF)
0
ACA
FLULAVAL QUAD
2016-2017
0
ACA
FLUZONE HIGHDOSE 2016-17 (PF)
0
ACA
FLUZONE
INTRADERM
QUAD 2016-17
0
ACA
FLUZONE QUAD
2016-2017
0
ACA
FLUZONE QUAD
2016-2017 (PF)
0
ACA
FLUZONE QUAD
PEDI 2016-17 (PF)
0
ACA
GAMASTAN S/D
4
PA
REBIF TITRATION
PACK
4
PA; LA
REVLIMID
4
PA; LA
ribasphere
4
LA
ribasphere ribapak
4
LA
ribavirin
4
LA
SYLATRON
4
PA; LA
TECFIDERA
4
PA; LA
ZINBRYTA
4
PA; LA
ACTIMMUNE
4
PA; LA
ALDARA
3
QL
ALFERON N
4
PA; LA
ARCALYST
4
PA; LA
ILARIS (PF)
4
PA; LA
imiquimod
1
QL
INTRON A
4
PA; LA
KINERET
4
PA; QL
PROLEUKIN
4
PA; LA
ZYCLARA
TOPICAL CREAM
IN METEREDDOSE PUMP 2.5 %
3
ZYCLARA
TOPICAL CREAM
IN METEREDDOSE PUMP 3.75
%
3
ZYCLARA
TOPICAL CREAM
IN PACKET
3
INTERLEUKINS
QL
QL
VACCINES & MISCELLANEOUS
IMMUNOLOGICALS
ACTHIB (PF)
0
ACA
71
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
MYOBLOC
4
PA; LA
NABI-HB
4
PA; LA
OCTAGAM
4
PA
ORALAIR
4
PA; LA
GAMMAGARD
LIQUID
4
PA
GAMMAGARD SD (IGA < 1
MCG/ML)
4
PA
GAMMAKED
4
PA
PEDIARIX (PF)
0
ACA
GAMMAPLEX
4
PA
PEDVAX HIB (PF)
0
ACA
GAMUNEX-C
4
PA
PENTACEL (PF)
0
ACA
GARDASIL (PF)
0
ACA
PNEUMOVAX 23
0
ACA
GARDASIL 9 (PF)
0
ACA
PREVNAR 13 (PF)
0
ACA
GRASTEK
3
PA
PRIVIGEN
4
PA
HAVRIX (PF)
0
ACA
PROQUAD (PF)
0
ACA
HEPAGAM B
4
PA; LA
QUADRACEL (PF)
0
ACA
HIZENTRA
4
PA
RAGWITEK
3
PA
HYPERHEP B S/D
4
PA; LA
0
ACA
HYPERHEP B S-D
NEONATAL
4
PA; LA
RECOMBIVAX HB
(PF)
ROTARIX
0
PA; ACA
HYPERRAB S/D
(PF)
4
PA; LA
ROTATEQ
VACCINE
0
PA; ACA
HYPERTET S/D
(PF)
3
PA
TENIVAC (PF)
0
ACA
0
ACA
HYQVIA
4
PA
INFANRIX (DTAP)
(PF)
0
ACA
TETANUS,DIPHTH
ERIA TOX
PED(PF)
0
ACA
IPOL
0
ACA
TETANUSDIPHTHERIA
TOXOIDS-TD
KINRIX (PF)
0
ACA
PA; LA
0
ACA
THYMOGLOBULI
N
4
MENACTRA (PF)
MENHIBRIX (PF)
0
ACA
TRUMENBA
0
ACA
MENOMUNE A/C/Y/W-135
0
ACA
TWINRIX (PF)
0
ACA
VAQTA (PF)
0
ACA
MENOMUNE A/C/Y/W-135 (PF)
0
ACA
VARIVAX (PF)
0
ACA
MENVEO A-C-YW-135-DIP (PF)
0
ACA
VARIZIG
0
PA; ACA
ZOSTAVAX (PF)
0
ACA
M-M-R II (PF)
0
ACA
72
Drug Name
Drug
Tier
Requirements
/ Limits
MUSCULOSKELETAL &
RHEUMATOLOGY
GOUT THERAPY
allopurinol
1
aloprim
1
COLCHICINE
3
colchicineprobenecid
1
COLCRYS
2
KRYSTEXXA
4
MITIGARE
3
probenecid
1
ULORIC
3
ZYLOPRIM
3
PA
PA; LA
OSTEOPOROSIS THERAPY
ACTONEL ORAL
TABLET 150 MG, 5
MG
3
ACTONEL ORAL
TABLET 35 MG
3
alendronate oral
solution
1
alendronate oral
tablet 10 mg, 5 mg
1
alendronate oral
tablet 35 mg, 70 mg
1
ATELVIA
3
BINOSTO
3
BONIVA
INTRAVENOUS
4
PA; LA
BONIVA ORAL
3
QL
EVISTA
3
FORTEO
4
FOSAMAX
3
Drug Name
Drug
Tier
Requirements
/ Limits
FOSAMAX PLUS
D ORAL TABLET
70 MG- 2,800 UNIT
3
QL
FOSAMAX PLUS
D ORAL TABLET
70 MG- 5,600 UNIT
3
ibandronate
intravenous
4
PA; LA
ibandronate oral
1
QL
PROLIA
4
PA; LA; QL
raloxifene
0
ACA
risedronate oral
tablet 150 mg, 5 mg
1
risedronate oral
tablet 35 mg
1
QL
risedronate oral
tablet,delayed
release (dr/ec)
1
PA
OTHER RHEUMATOLOGICALS
QL
PA
QL
QL
ACTEMRA
4
ARAVA
3
BENLYSTA
4
CUPRIMINE
2
DEPEN
TITRATABS
3
ENBREL
4
PA; LA; QL
ENBREL
SURECLICK
4
PA; LA; QL
HUMIRA
4
PA; LA; QL
HUMIRA
PEDIATRIC
CROHN'S START
4
PA; LA; QL
HUMIRA PEN
CROHN'S-UC-HS
START
4
PA; LA; QL
leflunomide
1
73
PA; LA
PA; LA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
ORENCIA
4
PA; LA
ANGELIQ
3
ORENCIA (WITH
MALTOSE)
4
PA; LA
AYGESTIN
3
camila
0
ORENCIA
CLICKJECT
4
PA; LA
CLIMARA
3
OTEZLA
4
PA; LA
CLIMARA PRO
3
OTEZLA
STARTER
4
PA; LA
COMBIPATCH
2
covaryx
1
OTREXUP (PF)
3
PA
covaryx h.s.
1
RASUVO (PF)
3
PA
CRINONE
3
RIDAURA
2
deblitane
0
ACA; QL
SAVELLA
3
PA
DELESTROGEN
3
PA
SIMPONI
4
PA; LA; QL
DEPO-ESTRADIOL
3
PA
SIMPONI ARIA
4
PA; LA; QL
3
XELJANZ
4
PA; LA; QL
DEPO-PROVERA
INTRAMUSCULA
R SOLUTION
XELJANZ XR
4
PA; LA
DEPO-PROVERA
INTRAMUSCULA
R SUSPENSION
0
ACA; QL
0
ACA; QL
OBSTETRICS & GYNECOLOGY
DIAPHRAGMS AND OTHER NONORAL CONTRACEPTIVES
Requirements
/ Limits
ACA; QL
CAYA
CONTOURED
0
ACA; QL
DEPO-PROVERA
INTRAMUSCULA
R SYRINGE
ACA; QL
0
ACA; OTC
DEPO-SUBQ
PROVERA 104
0
FC2 FEMALE
CONDOM
DIVIGEL
3
QL
FEMCAP
0
ACA
DUAVEE
2
LILETTA
0
ACA; LA
eemt
1
MIRENA
0
ACA
eemt hs
1
PARAGARD T
380A
0
ACA
ELESTRIN
3
QL
SKYLA
0
ACA
ENDOMETRIN
3
PA
WIDE-SEAL
DIAPHRAGM
0
ACA
errin
0
ACA; QL
ESTRACE ORAL
3
ESTRACE
VAGINAL
2
estradiol
1
ESTROGENS & PROGESTINS
ACTIVELLA
3
ALORA
3
74
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
PA
norethindrone
(contraceptive)
0
norethindrone
acetate
1
norethindrone ac-eth
estradiol
1
norlyroc
0
ACA; QL
NOR-QD
0
ACA; QL
ORTHO
MICRONOR
0
PA; ACA; QL
PREFEST
3
PREMARIN
INJECTION
3
PREMARIN ORAL
2
PREMARIN
VAGINAL
2
PREMPHASE
2
PREMPRO
2
progesterone
4
progesterone
micronized
1
PROMETRIUM
3
PROVERA
3
sharobel
0
VAGIFEM
2
VIVELLE-DOT
3
estradiol valerate
1
estradiolnorethindrone acet
1
ESTRING
2
ESTROGEL
3
estrogensmethyltestosterone
1
estropipate
1
EVAMIST
2
FEMHRT LOW
DOSE
3
FEMRING
3
fyavolv
1
heather
0
hydroxyprogesterone
caproate
1
jencycla
0
jevantique lo
1
jinteli
1
jolivette
0
lopreeza
1
lyza
0
MAKENA
4
medroxyprogesteron
e intramuscular
0
medroxyprogesteron
e oral
1
MENEST
3
AVC VAGINAL
3
MENOSTAR
3
CERVIDIL
3
mimvey
1
CLEOCIN
VAGINAL CREAM
3
mimvey lo
1
3
nora-be
0
CLEOCIN
VAGINAL
SUPPOSITORY
2
MINIVELLE
QL
QL
ACA; QL
ACA; QL
ACA; QL
ACA; QL
ACA; QL
MISCELLANEOUS OB/GYN
ACA; QL
75
Requirements
/ Limits
ACA; QL
PA
ACA; QL
Drug Name
Drug
Tier
clindamycin
phosphate
1
CLINDESSE
3
CONCEPTROL
0
fem ph
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
VCF
CONTRACEPTIVE
FILM
0
ACA; OTC
0
ACA; OTC
1
VCF
CONTRACEPTIVE
GEL
GYNAZOLE-1
3
xulane
0
PA; ACA; QL
isoxsuprine
1
LUPANETA PACK
(1 MONTH)
4
ORAL CONTRACEPTIVES &
RELATED AGENTS
LUPANETA PACK
(3 MONTH)
4
LYSTEDA
ACA; OTC
AFTERA
0
ACA; OTC;
QL
altavera (28)
0
ACA; QL
3
alyacen 1/35 (28)
0
ACA; QL
METROGEL
VAGINAL
3
alyacen 7/7/7 (28)
0
ACA; QL
metronidazole
1
amethia
0
PA; ACA; QL
miconazole-3
1
amethia lo
0
PA; ACA; QL
NEXPLANON
0
ACA
amethyst
0
ACA; QL
NUVARING
0
ACA; QL
apri
0
ACA; QL
NUVESSA
3
aranelle (28)
0
ACA; QL
OSPHENA
3
ashlyna
0
ACA; QL
PREPIDIL
3
aubra
0
ACA; QL
PROSTIN E2
3
aviane
0
ACA; QL
RELAGARD
3
azurette (28)
0
ACA; QL
TERAZOL 3
3
balziva (28)
0
ACA; QL
TERAZOL 7
3
bekyree (28)
0
ACA; QL
0
PA; ACA; QL
1
BEYAZ
terconazole
TODAY
CONTRACEPTIVE
SPONGE
0
blisovi 24 fe
0
ACA; QL
blisovi fe 1.5/30 (28)
0
ACA; QL
blisovi fe 1/20 (28)
0
ACA; QL
tranexamic acid
1
BREVICON (28)
0
PA; ACA; QL
vaginal
contraceptive foam
0
briellyn
0
ACA; QL
camrese
0
PA; ACA; QL
vandazole
1
camrese lo
0
PA; ACA; QL
ACA; OTC
ACA; OTC
76
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
caziant (28)
0
ACA; QL
gildagia
0
ACA; QL
chateal
0
ACA; QL
gildess 1.5/30 (21)
0
ACA; QL
cryselle (28)
0
ACA; QL
gildess 1/20 (21)
0
ACA; QL
cyclafem 1/35 (28)
0
ACA; QL
gildess 24 fe
0
ACA; QL
cyclafem 7/7/7 (28)
0
ACA; QL
gildess fe 1.5/30 (28)
0
ACA; QL
CYCLESSA (28)
0
PA; ACA; QL
gildess fe 1/20 (28)
0
ACA; QL
cyred
0
ACA; QL
introvale
0
ACA; QL
dasetta 1/35 (28)
0
ACA; QL
jolessa
0
ACA; QL
dasetta 7/7/7 (28)
0
ACA; QL
juleber
0
ACA; QL
daysee
0
ACA; QL
junel 1.5/30 (21)
0
ACA; QL
delyla (28)
0
ACA; QL
junel 1/20 (21)
0
ACA; QL
desoge.estradiol/e.estradio
l
0
ACA; QL
junel fe 1.5/30 (28)
0
ACA; QL
junel fe 1/20 (28)
0
ACA; QL
DESOGEN
0
PA; ACA; QL
junel fe 24
0
ACA; QL
desogestrel-ethinyl
estradiol
0
ACA; QL
kaitlib fe
0
ACA; QL
kariva (28)
0
ACA; QL
drospirenone-ethinyl
estradiol
0
kelnor 1/35 (28)
0
ACA; QL
kimidess (28)
0
ACA; QL
econtra ez
0
ACA; OTC;
QL
kurvelo
0
ACA; QL
elinest
0
ACA; QL
l norgest/e.estradiole.estrad
0
ACA; QL
ELLA
0
PA; ACA; QL
larin 1.5/30 (21)
0
ACA; QL
emoquette
0
ACA; QL
larin 1/20 (21)
0
ACA; QL
enpresse
0
ACA; QL
larin 24 fe
0
ACA; QL
enskyce
0
ACA
larin fe 1.5/30 (28)
0
ACA; QL
estarylla
0
ACA; QL
larin fe 1/20 (28)
0
ACA; QL
ESTROSTEP FE-28
0
PA; ACA; QL
layolis fe
0
ACA; QL
fallback solo
0
ACA; OTC;
QL
leena 28
0
ACA; QL
falmina (28)
0
ACA; QL
lessina
0
ACA; QL
FEMCON FE
0
PA; ACA; QL
levonest (28)
0
ACA; QL
GENERESS FE
0
PA; ACA; QL
levonorgestrelethinyl estrad
0
ACA; QL
gianvi (28)
0
ACA; QL
ACA; QL
77
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
myzilra
0
ACA; QL
NATAZIA
0
PA; ACA; QL
necon 0.5/35 (28)
0
ACA; QL
necon 1/35 (28)
0
ACA; QL
necon 1/50 (28)
0
ACA; QL
necon 10/11 (28)
0
ACA; QL
necon 7/7/7 (28)
0
ACA; QL
levonorg-eth estrad
triphasic
0
ACA; QL
levora-28
0
ACA; QL
LO LOESTRIN FE
0
PA; ACA; QL
LOESTRIN 1.5/30
(21)
0
ACA; QL
LOESTRIN 1/20
(21)
0
ACA; QL
LOESTRIN FE
1.5/30 (28-DAY)
0
PA; ACA; QL
next choice one dose
0
ACA; OTC;
QL
LOESTRIN FE 1/20
(28-DAY)
0
PA; ACA; QL
nikki (28)
0
ACA; QL
0
ACA; QL
lomedia 24 fe
0
ACA; QL
noreth-ethinyl
estradiol-iron
loryna (28)
0
ACA; QL
0
ACA; QL
LOSEASONIQUE
0
PA; ACA; QL
norethindrone ac-eth
estradiol
low-ogestrel (28)
0
ACA; QL
norethindronee.estradiol-iron
0
ACA; QL
lutera (28)
0
ACA; QL
ACA; QL
0
ACA; QL
norgestimate-ethinyl
estradiol
0
marlissa
microgestin 1.5/30
(21)
0
ACA; QL
NORINYL 1+35
(28)
0
PA; ACA; QL
microgestin 1/20
(21)
0
ACA; QL
nortrel 0.5/35 (28)
0
ACA; QL
nortrel 1/35 (21)
0
ACA; QL
MICROGESTIN 24
FE
0
PA; ACA; QL
nortrel 7/7/7 (28)
0
ACA; QL
microgestin fe 1.5/30
(28)
0
ACA; QL
ocella
0
PA; ACA; QL
ogestrel (28)
0
ACA; QL
microgestin fe 1/20
(28)
0
ACA; QL
opcicon one-step
0
ACA; OTC;
QL
MINASTRIN 24 FE
0
PA; ACA; QL
orsythia
0
ACA; QL
MIRCETTE (28)
0
PA; ACA; QL
0
PA; ACA; QL
MODICON (28)
0
PA; ACA; QL
ORTHO TRICYCLEN (28)
mono-linyah
0
ACA; QL
ORTHO TRICYCLEN LO (28)
0
PA; ACA; QL
mononessa (28)
0
ACA; QL
PA; ACA; QL
0
ACA; OTC;
QL
ORTHO-CYCLEN
(28)
0
my way
78
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
ORTHO-NOVUM
1/35 (28)
0
PA; ACA; QL
trinessa (28)
0
ACA; QL
trinessa lo
0
ACA; QL
ORTHO-NOVUM
7/7/7 (28)
0
PA; ACA; QL
TRI-NORINYL (28)
0
PA; ACA; QL
OVCON-35 (28)
0
PA; ACA; QL
tri-previfem (28)
0
ACA; QL
philith
0
ACA; QL
tri-sprintec (28)
0
ACA; QL
pimtrea (28)
0
ACA; QL
trivora (28)
0
ACA; QL
pirmella
0
ACA; QL
velivet triphasic
regimen (28)
0
ACA; QL
PLAN B ONESTEP
0
ACA; QL
vestura (28)
0
ACA; QL
portia
0
ACA; QL
vienva
0
ACA; QL
previfem
0
ACA; QL
viorele (28)
0
PA; ACA; QL
QUARTETTE
0
PA; ACA; QL
vyfemla (28)
0
ACA; QL
quasense
0
ACA; QL
wera (28)
0
ACA; QL
react
0
ACA; OTC;
QL
wymzya fe
0
ACA; QL
YASMIN (28)
0
PA; ACA; QL
reclipsen (28)
0
ACA; QL
YAZ (28)
0
PA; ACA; QL
SAFYRAL
0
PA; ACA; QL
zarah
0
PA; ACA; QL
SEASONIQUE
0
PA; ACA; QL
zenchent (28)
0
PA; ACA; QL
setlakin
0
ACA; QL
zenchent fe
0
PA; ACA; QL
sprintec (28)
0
ACA; QL
zovia 1/35e (28)
0
ACA; QL
sronyx
0
ACA; QL
zovia 1/50e (28)
0
ACA; QL
syeda
0
ACA; QL
OXYTOCICS
TAKE ACTION
0
ACA; OTC;
QL
methergine
1
methylergonovine
1
tarina fe 1/20 (28)
0
ACA; QL
tilia fe
0
ACA; QL
tri-estarylla
0
ACA; QL
tri-legest fe
0
ACA; QL
tri-linyah
0
ACA; QL
tri-lo-estarylla
0
tri-lo-marzia
tri-lo-sprintec
OPHTHALMOLOGY
ANTIBIOTICS
AZASITE
3
bacitracin
1
ACA; QL
bacitracinpolymyxin b
1
0
ACA; QL
BESIVANCE
3
0
ACA; QL
79
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
trifluridine
1
VIROPTIC
3
ZIRGAN
3
Requirements
/ Limits
BETADINE
OPHTHALMIC
PREP
3
CILOXAN
3
ciprofloxacin hcl
1
erythromycin
1
gatifloxacin
1
gentak
1
gentamicin
1
ILOTYCIN
3
levofloxacin
1
MOXEZA
3
NATACYN
3
neomycinbacitracinpolymyxin
1
neomycinpolymyxingramicidin
1
neo-polycin
1
NEOSPORIN
(NEO-POLYMGRAMICID)
3
OCUFLOX
3
CYCLOPLEGIC MYDRIATICS
ofloxacin
1
atropine
1
polycin
1
2
polymyxin b sulftrimethoprim
1
CYCLOGYL
OPHTHALMIC
DROPS 0.5 %
POLYTRIM
3
3
tobramycin
1
CYCLOGYL
OPHTHALMIC
DROPS 1 %, 2 %
TOBREX
3
cyclopentolate
1
VIGAMOX
3
homatropaire
1
ZYMAXID
3
homatropine hbr
1
ISOPTO
ATROPINE
3
ANTIVIRALS
BETA-BLOCKERS
BETAGAN
3
betaxolol
1
BETIMOL
3
BETOPTIC S
3
carteolol
1
ISTALOL
3
levobunolol
1
metipranolol
1
timolol maleate
1
TIMOPTIC
3
TIMOPTIC
OCUDOSE (PF)
3
TIMOPTIC-XE
3
CHOLINESTERASE INHIBITOR
MIOTICS
PHOSPHOLINE
IODIDE
80
2
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
MYDRIACYL
3
LACRISERT
3
PAREMYD
3
LASTACAFT
3
tropicamide
1
LUCENTIS
4
PA
DIRECT ACTING MIOTICS
MACUGEN
4
PA; LA
ISOPTO CARPINE
3
olopatadine
1
MIOCHOL-E
3
OMIDRIA
3
pilocarpine hcl
1
PATADAY
3
PATANOL
2
PAZEO
3
MISCELLANEOUS
OPHTHALMOLOGICS
PA
acuicyn
1
proparacaine
1
AKTEN (PF)
3
RESTASIS
3
ALCAINE
3
tetcaine
1
ALOCRIL
2
tetracaine hcl
1
ALOMIDE
2
tetracaine hcl (pf)
1
altacaine
1
TETRAVISC
3
altafluor
1
3
AVENOVA
3
TETRAVISC
FORTE
azelastine
1
VISUDYNE
4
PA; LA
BEPREVE
3
VITRASE
3
PA
cromolyn
1
CYSTARAN
4
NON-STEROIDAL ANTIINFLAMMATORY AGENTS
ELESTAT
3
EMADINE
3
epinastine
1
EYLEA
4
flucaine
1
fluoresceinbenoxinate
1
fluoresceinproparacaine
1
flurox
1
JETREA (PF)
4
PA; LA
PA
ACULAR
3
ACULAR LS
3
ACUVAIL (PF)
3
bromfenac
1
diclofenac sodium
1
flurbiprofen sodium
1
ILEVRO
3
ketorolac
1
NEVANAC
3
OCUFEN
3
PROLENSA
3
81
QL
Drug Name
Drug
Tier
Requirements
/ Limits
ORAL DRUGS FOR GLAUCOMA
Drug Name
Drug
Tier
neomycin-polymyxin
b-dexameth
1
neomycinpolymyxin-hc
1
neo-polycin hc
1
PRED-G
2
acetazolamide
1
acetazolamide
sodium
1
DIAMOX
SEQUELS
3
methazolamide
1
PRED-G S.O.P.
2
NEPTAZANE
3
TOBRADEX
3
OTHER GLAUCOMA DRUGS
TOBRADEX ST
3
AZOPT
3
1
COMBIGAN
3
tobramycindexamethasone
COSOPT
3
ZYLET
2
COSOPT (PF)
3
dorzolamide
1
dorzolamide-timolol
1
latanoprost
1
LUMIGAN
3
PA
miostat
1
PA
MITOSOL
3
RESCULA
3
SIMBRINZA
3
TRAVATAN Z
3
travoprost
(benzalkonium)
1
TRUSOPT
3
XALATAN
3
ZIOPTAN (PF)
3
PA
STEROIDS
PA
PA
STEROID-ANTIBIOTIC
COMBINATIONS
MAXITROL
3
neomycinbacitracin-poly-hc
1
Requirements
/ Limits
ALREX
3
dexamethasone
sodium phosphate
1
DUREZOL
3
FLAREX
3
fluorometholone
1
FML FORTE
3
FML LIQUIFILM
3
FML S.O.P.
3
ILUVIEN
4
LOTEMAX
3
MAXIDEX
3
OMNIPRED
3
PRED FORTE
3
PRED MILD
2
prednisolone acetate
1
prednisolone sodium
phosphate
1
RETISERT
4
VEXOL
2
82
QL
PA
PA; LA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
STEROID-SULFONAMIDE
COMBINATIONS
CLARINEX ORAL
SYRUP
3
PA
BLEPHAMIDE
2
3
PA; QL
BLEPHAMIDE
S.O.P.
2
CLARINEX ORAL
TABLET
clemastine
1
sulfacetamideprednisolone
1
cyproheptadine
1
desloratadine
1
PA; QL
diphenhydramine hcl
injection
1
PA
diphenhydramine hcl
oral
1
epinephrine
injection autoinjector
1
PA; QL
epinephrine
injection solution
1
PA
epinephrine
injection syringe
1
PA
SULFONAMIDES
BLEPH-10
3
sulfacetamide
sodium
1
SYMPATHOMIMETICS
ALPHAGAN P
OPHTHALMIC
DROPS 0.1 %
2
ALPHAGAN P
OPHTHALMIC
DROPS 0.15 %
3
apraclonidine
1
EPIPEN 2-PAK
2
QL
brimonidine
1
EPIPEN JR 2-PAK
2
QL
IOPIDINE
3
EPISNAP
3
hydroxyzine hcl
intramuscular
1
hydroxyzine hcl oral
1
hydroxyzine
pamoate
1
RESPIRATORY, ALLERGY,
COUGH & COLD
KARBINAL ER
3
levocetirizine
1
ANTIHISTAMINE &
ANTIALLERGENIC AGENTS
phenadoz
1
VASOCONSTRICTOR
DECONGESTANTS
CYCLOMYDRIL
3
phenylephrine hcl
1
ADRENACLICK
3
PA; QL
PHENERGAN
INJECTION
3
adrenalin
1
PA
phenergan rectal
1
arbinoxa
1
1
carbinoxamine
maleate
1
promethazine
injection
promethazine oral
1
cetirizine
1
83
PA
PA
PA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
promethazine rectal
1
M-END MAX D
3
promethegan
1
M-END PE
3
VISTARIL
3
NINJACOF-XG
3
XYZAL
3
OBREDON
3
COUGH & COLD THERAPY
phenylhistine dh
1
benzonatate
1
POLY-TUSSIN AC
3
BROMFED DM
3
promethazine vc
1
brompheniraminepseudoeph-dm
1
promethazine vccodeine
1
CAPCOF
3
1
centergy
1
promethazinecodeine
cheratussin ac
1
promethazine-dm
1
cheratussin dac
1
promethazinephenyleph-codeine
1
CLARINEX-D 12
HOUR
3
3
codeine-guaifenesin
1
PRO-RED AC (W/
DEXCHLORPHENI
R)
FLOWTUSS
3
relcof c
1
guaifenesin ac
1
RESPA-AR
3
guaifenesin dac
1
REZIRA
3
HISTEX-AC
3
rydex
1
HYCOFENIX
3
SEMPREX-D
3
hydrocodonechlorpheniramine
1
TESSALON
PERLES
3
hydrocodone-cpmpseudoephed
1
tusnel c
1
3
hydrocodonehomatropine
1
TUSNEL
PEDIATRIC
TUSSICAPS
3
hydromet
1
tussigon
1
iophen c-nr
1
1
TUSSIONEX
PENNKINETIC ER
3
lortuss ex
MAR-COF BP
3
TUZISTRA XR
3
MAR-COF CG
3
virtussin ac
1
m-clear wc
1
virtussin dac
1
PA; QL
PA
PA
84
Requirements
/ Limits
PA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
PA
AEROSPAN
3
Requirements
/ Limits
VITUZ
3
ZODRYL AC 25
3
albuterol sulfate
1
ZODRYL AC 30
3
ALVESCO
3
ZODRYL AC 35
3
ANORO ELLIPTA
3
ZODRYL AC 40
3
3
ZODRYL AC 50
3
ARCAPTA
NEOHALER
ZODRYL AC 60
3
ARNUITY
ELLIPTA
3
PA
ZODRYL AC 80
3
ASMANEX HFA
2
QL
ZODRYL DAC 25
3
2
QL
ZODRYL DAC 30
3
ASMANEX
TWISTHALER
ZODRYL DAC 35
3
ATROVENT HFA
2
ZODRYL DAC 40
3
BECONASE AQ
3
ST
ZODRYL DAC 50
3
BERINERT
4
PA; LA
ZODRYL DAC 60
3
3
ZODRYL DAC 80
3
BEVESPI
AEROSPHERE
ZODRYL DEC 25
3
BREO ELLIPTA
3
ZODRYL DEC 30
3
BROVANA
3
ZODRYL DEC 35
3
budesonide
inhalation
1
ZODRYL DEC 40
3
budesonide nasal
1
ZODRYL DEC 50
3
ST; OTC
3
CHILDREN'S
NASACORT
2
ZODRYL DEC 60
ZODRYL DEC 80
3
CINQAIR
4
PA; LA
ZONATUSS
3
CINRYZE
4
PA; LA
Z-TUSS AC
3
2
ZUTRIPRO
3
COMBIVENT
RESPIMAT
PULMONARY AGENTS
cromolyn
1
ACCOLATE
3
CUROSURF
3
acetylcysteine
1
DALIRESP
3
ADCIRCA
4
PA; LA
DULERA
2
ADEMPAS
4
PA; LA
DYMISTA
3
ADVAIR DISKUS
3
PA; QL
ELIXOPHYLLIN
3
ADVAIR HFA
3
PA; QL
ESBRIET
4
85
PA
PA
QL
QL
ST
PA; LA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
FIRAZYR
4
PA; LA; QL
PROVENTIL HFA
3
PA
FLOVENT DISKUS
3
PA; QL
PULMICORT
3
PA; QL
FLOVENT HFA
3
PA; QL
3
PA
flunisolide
1
PULMICORT
FLEXHALER
fluticasone
1
pulmosal
1
FORADIL
AEROLIZER
3
PULMOZYME
4
QNASL
3
HYPER-SAL
3
QVAR
2
INCRUSE
ELLIPTA
3
REVATIO
INTRAVENOUS
4
PA; LA; QL
ipratropium bromide
1
4
PA; LA
ipratropiumalbuterol
1
REVATIO ORAL
SUSPENSION FOR
RECONSTITUTIO
N
KALBITOR
4
PA; LA
PA; LA; QL
4
PA; LA; QL
REVATIO ORAL
TABLET
4
KALYDECO
LETAIRIS
4
PA; LA; QL
RUCONEST
4
PA; LA
levalbuterol hcl
1
3
PA
metaproterenol
1
SEEBRI
NEOHALER
mometasone
1
SEREVENT
DISKUS
2
montelukast
1
PA; QL
2
ST; OTC
sildenafil
intravenous
4
NASACORT
nasal allergy
1
OTC
sildenafil oral
4
PA; LA; QL
NASONEX
3
PA
SINGULAIR
3
NEBUSAL
3
sodium chloride
1
NUCALA
4
PA; LA
3
PA
OFEV
4
PA; LA
SPIRIVA
RESPIMAT
OMNARIS
3
ST
SPIRIVA WITH
HANDIHALER
3
PA
OPSUMIT
4
PA; LA
4
PA; LA
STIOLTO
RESPIMAT
3
ORKAMBI
PERFOROMIST
3
3
PROAIR HFA
2
STRIVERDI
RESPIMAT
PROAIR
RESPICLICK
2
SURFAXIN
3
SYMBICORT
2
PA
86
ST
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
DETROL LA
3
DITROPAN XL
3
ENABLEX
3
flavoxate
1
GELNIQUE
3
PA
MYRBETRIQ
3
PA
oxybutynin chloride
1
OXYTROL
3
tolterodine
1
TOVIAZ
3
PA
trospium
1
PA
3
PA
terbutaline oral
1
terbutaline
subcutaneous
1
THEO-24
3
theochron
1
theophylline
1
TRACLEER
4
TUDORZA
PRESSAIR
2
TYVASO
4
TYVASO REFILL
KIT
4
TYVASO
STARTER KIT
4
PA; LA; QL
VESICARE
UTIBRON
NEOHALER
3
PA
BENIGN PROSTATIC HYPERPLASIA
(BPH) THERAPY
VENTAVIS
4
PA; LA
VENTOLIN HFA
3
PA
VERAMYST
3
PA
VOSPIRE ER
3
XOLAIR
4
XOPENEX
PA
ST; LA; QL
PA
alfuzosin
1
AVODART
3
QL
CIALIS
3
PA; QL
dutasteride
1
QL
dutasteridetamsulosin
1
3
finasteride
1
QL
XOPENEX
CONCENTRATE
3
FLOMAX
3
QL
JALYN
3
XOPENEX HFA
3
PROSCAR
3
QL
zafirlukast
1
RAPAFLO
2
ST
ZETONNA
3
tamsulosin
1
QL
ZYFLO
3
UROXATRAL
3
ZYFLO CR
3
PA; LA
PA
ST
PA
UROLOGICALS
ANTICHOLINERGICS &
ANTISPASMODICS
darifenacin
1
DETROL
3
CHOLINERGIC STIMULANTS
bethanechol chloride
1
URECHOLINE
3
MISCELLANEOUS UROLOGICALS
alprostadil
87
1
PA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
PA
uramit mb
1
URELLE
3
uretron d-s
1
URIBEL
3
urimar-t
1
urin ds
1
UROCIT-K 10
3
UROCIT-K 15
3
UROCIT-K 5
3
urogesic-blue
1
uro-l
1
urolet mb
1
uro-mp
1
urophen mb
1
UROQID-ACID
NO.2
3
uryl
1
ustell
1
UTA
3
utira-c
1
Requirements
/ Limits
AMMONIUM
CHLORIDE
3
azuphen mb
1
CYSTAGON
4
cytra k crystals
1
cytra-2
1
cytra-3
1
cytra-k
1
ELMIRON
3
hyolev mb
1
hyophen
1
INDIOMIN MB
3
K-PHOS NO 2
3
K-PHOS
ORIGINAL
3
methen-sod phosmeth blue-hyos
1
ORACIT
3
phosphasal
1
pot,sodium citratecitric acid
1
potassium citrate
1
virtrate-2
1
potassium citratecitric acid
1
virtrate-3
1
virtrate-k
1
PROCYSBI
4
PA; LA
PROSTIN VR
PEDIATRIC
3
PA
RENACIDIN
3
SHOHL'S
MODIFIED
3
VITAMINS, HEMATINICS &
ELECTROLYTES
sodium citrate-citric
acid
1
ELECTROLYTES
tricitrates
1
ur n-c
1
URINARY ANESTHETICS
phenazopyridine
1
PYRIDIUM
3
calcium 500 with d
0
ACA; OTC
calcium carb and
citrate-vitd3
0
ACA; OTC
88
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
calcium citrate + d
0
ACA; OTC
potassium acetate
1
calcium citratevitamin d2
0
ACA; OTC
potassium bicarb
and chloride
1
EFFER-K ORAL
TABLET,
EFFERVESCENT
10 MEQ, 20 MEQ
3
potassium bicarbcitric acid
1
potassium chloridd5-0.45%nacl
1
PA
effer-k oral tablet,
effervescent 25 meq
1
potassium chloride
in 0.9%nacl
1
PA
GALZIN
3
PA
3
potassium chloride
in 5 % dex
1
GLYCOPHOS
k-effervescent
1
1
PA
klor-con
1
potassium chloride
in lr-d5
klor-con 10
1
potassium chloride
intravenous
1
PA
klor-con 8
1
1
potassium chloride
oral
1
klor-con m10
klor-con m15
1
1
PA
klor-con m20
1
potassium chloride0.45 % nacl
klor-con sprinkle
1
potassium chlorided5-0.2%nacl
1
PA
KLOR-CON/25
3
PA
1
1
klor-con/ef
k-phos-neutral
1
1
PA
k-sol
1
K-TAB ORAL
TABLET
EXTENDED
RELEASE 10 MEQ,
20 MEQ
3
potassium phosphate
m-/d-basic
1
PA
sodium chloride
1
PA
1
PA
k-tab oral tablet
extended release 8
meq
1
sodium chloride 0.45
% intravenous
parenteral solution
1
lugols
1
sodium chloride 0.45
% intravenous
piggyback
NORMOSOL-R
3
sodium chloride 3 %
1
PA
phospha 250 neutral
1
sodium chloride 5 %
1
PA
POTABA
3
sodium phosphate
1
PA
PA
PA
PA
89
PA
Drug Name
Drug
Tier
strong iodine
1
virt-phos 250 neutral
1
Requirements
/ Limits
MISCELLANEOUS VITAMINS,
HEMATINICS, & ELECTROLYTES
Drug Name
Drug
Tier
calcium-folic acidvitamin d
1
CARDIOTEK-RX
(BIOPERINE)
3
centratex
1
FORTAVIT
3
ISOLYTE S PH 7.4
3
PA
chewable multivita,b,d,e,k,zn
1
ISOLYTE-S
3
PA
ciferex
1
NORMOSOL-R PH
7.4
3
PA
CITRANATAL
(DUAL-IRON)
3
PLASMA-LYTE
148
3
PA
CITRANATAL 90
DHA (ALGAL OIL)
3
PLASMA-LYTE A
3
PA
CITRANATAL
ASSURE
3
CITRANATAL BCALM (FE GLUC)
3
VITAMINS & HEMATINICS
ACTIVE FE
3
ACTIVE OB
3
ANIMI-3 WITH
VITAMIN D
3
CITRANATAL
DHA (ALGAL OIL)
3
ATABEX EC
3
3
b complex 100
1
PA
CITRANATAL
HARMONY (IRON
FUM)
b complex-vitamin
b12
0
ACA; OTC
classic prenatal
0
c-nate dha
1
b complex-vitamin cfolic acid
0
ACA; OTC
3
BACMIN
3
COMPLETE
FORMULATION
D3000
balanced b-100
complex
0
ACA; OTC
3
bal-care dha
1
COMPLETE
FORMULATION
PEDIATRIC
BAL-CARE DHA
ESSENTIAL
3
complete natal dha
1
completenate
1
b-complex with
vitamin c
0
CONCEPT DHA
3
CONCEPT OB
3
BIFERA RX
3
corvita
1
CADEAU DHA
3
corvita 150
1
calcium pnv
1
CORVITE
3
ACA; OTC
90
Requirements
/ Limits
ACA; OTC
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
CORVITE 150
3
fe c plus
1
CORVITE FE
3
FERAHEME
3
CORVITE FREE
3
3
cyanocobalamin
(vitamin b-12)
1
FERIVA 21-7
TABLET
3
dialyvite
1
FERIVA FA
(SUMALATE)
DIALYVITE 3000
3
ferocon
1
DIALYVITE 5000
3
3
dialyvite 800
0
FERRALET 90
DUAL-IRON
DELIVERY
DIALYVITE 800
WITH IRON
3
ferraplus 90
1
ferrex 150 forte
1
DIALYVITE
SUPREME D
3
ferrex 150 forte plus
1
dothelle dha
1
ferrex 28
1
DRISDOL
3
ferrocite plus
1
DUET DHA
BALANCED
3
ferrogels forte
1
FLORIVA
3
DUET DHA WITH
OMEGA-3
3
3
DURACHOL
3
FLORIVA
(FLUORIDEVITAMIN D3)
ELDERCAPS
3
FLORIVA PLUS
3
ENLYTE
(FERROUS
GLYCINE)
3
FLUORABON
3
FLUOR-A-DAY
3
1
ESCAVITE
3
fluor-a-day (with
xylitol) oral
tablet,chewable 0.25
mg f (0.55 mg)236.79mg
0
ergocalciferol
(vitamin d2)
ESCAVITE D
3
3
EXPECTA
PRENATAL
3
fluor-a-day (with
xylitol) oral
tablet,chewable 1
mg f (2.2 mg)-236.79
mg
1
ESCAVITE LQ
EXTRA-VIRT
PLUS DHA
2
FLUORITAB
ORAL DROPS
3
FA-8
3
fabb
1
ACA; OTC
OTC
OTC
91
Requirements
/ Limits
PA
ACA
Drug Name
Drug
Tier
Requirements
/ Limits
Drug Name
Drug
Tier
ACA
hematinic plus
vit/minerals
1
hematinic/folic acid
1
hematogen
1
hematogen fa
1
Requirements
/ Limits
fluoritab oral
tablet,chewable 0.5
mg fluoride (1.1 mg)
0
fluoritab oral
tablet,chewable 1
1
FLURA-DROPS
3
hematogen forte
1
focalgin 90 dha
1
HEMATRON
3
focalgin ca
1
HEMATRON-AF
3
focalgin dss
1
HEMAX
3
folbecal
1
hemenatal ob
1
folbee
1
hemenatal ob + dha
1
folbee ar
1
hemetab
1
folbee plus
1
HEMOCYTE-F
3
FOLET DHA
3
HEMOCYTE-PLUS
3
FOLET ONE
3
hydroxocobalamin
1
FOLGARD OS
3
ICAR-C PLUS
3
FOLGARD RX
3
iferex 150 forte
1
folic acid injection
1
inatal advance
1
folic acid oral tablet
1 mg
1
inatal ultra
1
infed
1
PA
folic acid oral tablet
400 mcg, 800 mcg
0
INFUVITE ADULT
3
PA
folic acid-vit b6-vit
b12
1
INFUVITE
PEDIATRIC
3
PA
folivane-f
1
INJECTAFER
3
PA
folivane-ob
1
INTEGRA F
3
folivane-plus
1
INTEGRA PLUS
3
folplex 2.2
1
IROSPAN 24/6
3
foltabs 800
0
levomefolate dha
1
FOLTRATE
3
0
full spectrum bvitamin c
0
FUSION PLUS
3
ludent fluoride oral
mg fluorid (0.55
mg), 0.5 mg fluoride
(1.1 mg)
PA
ACA; OTC
ACA; OTC
ACA; OTC
92
PA
ACA
Drug Name
Drug
Tier
Requirements
/ Limits
ludent fluoride oral
tablet,chewable 1
1
M.V.I. PEDIATRIC
2
PA
M.V.I.-12
(WITHOUT
VITAMIN K)
3
PA
macnatal cn dha
Drug Name
Drug
Tier
mvc-fluoride oral
mg, 0.5 mg
0
mvc-fluoride oral
tablet,chewable 1
mg
1
M-VIT
3
1
myferon 150 forte
1
MARNATAL-F
3
mynatal
1
MAXARON
FORTE
3
mynatal advance
1
mynatal plus
1
MAXFE (FOLATEDOCUSATE)
3
mynatal-z
1
MAXINATE
3
mynate 90 plus
1
multi-delyn with iron
1
mynephrocaps
1
multigen folic
1
NATACHEW (FE
BIS-GLYCINATE)
3
multigen plus
1
NATELLE ONE
3
multi-vit with
fluoride-iron
0
ACA
natural b-100
complex
0
multi-vitamin with
fluoride oral drops
0
ACA
3
multi-vitamin with
fluoride oral
mg, 0.5 mg
0
ACA
NEEVODHA
(WITH ALGAL
OIL)
nephplex rx
1
NEPHROCAPS
3
multi-vitamin with
fluoride oral
tablet,chewable 1
mg
1
NEPHROCAPS QT
3
NEPHRON FA
3
NEPHRO-VITE
3
multivitamins with
fluoride oral
mg, 0.5 mg
0
nephro-vite rx
1
NESTABS
3
NESTABS ABC
3
multivitamins with
fluoride oral
tablet,chewable 1
mg
1
NESTABS DHA
3
NEURIN-SL
3
newgen
1
NEXA PLUS
3
OTC
ACA
93
Requirements
/ Limits
ACA
ACA; OTC
OTC
Drug Name
Drug
Tier
NEXAVIR
3
NICOMIDE
3
NICOMIDE
(SELENIUMCHROMIUM)
3
NIVA-FOL
3
NIVA-PLUS
3
NUFERA
3
NUTRICAP
3
OB COMPLETE
3
OB COMPLETE
GOLD
3
OB COMPLETE
ONE
3
OB COMPLETE
PETITE
3
OB COMPLETE
PREMIER
3
OB COMPLETE
WITH DHA
3
obstetrix dha
1
OBSTETRIX EC
3
OBTREX DHA
3
O-CAL FA
3
O-CAL
PRENATAL
3
ONE A DAY
WOMEN'S
PRENATAL DHA
3
ONE DAILY
PRENATAL ORAL
COMBO PACK 28
MG IRON- 800
MCG
3
one daily prenatal
oral combo pack 28800-440 mg-mcg-mg
0
Requirements
/ Limits
Drug Name
PA
ortho d
1
PAIRE OB PLUS
DHA
3
PED
MULTIVITAMINSA,B,D,E,K,ZN
3
perry prenatal
0
pnv 29-1
1
pnv ob+dha
1
pnv-dha
1
pnv-dha + docusate
1
pnv-ferrous
fumarate-docu-fa
1
pnv-omega
1
pnv-select
1
pnv-vp-u
1
poly-iron 150 forte
1
POLY-VI-FLOR
3
POLY-VI-FLOR FS
3
POLY-VI-FLOR
WITH IRON
3
poly-vitamin with
iron
0
pr natal 400
1
pr natal 400 ec
1
pr natal 430
1
pr natal 430 ec
1
PREFERA-OB
3
PREFERA-OB ONE
3
PREFERA-OB
PLUS DHA
3
prena1 chew
1
prena1 pearl
1
prenaissance
1
OTC
OTC
ACA; OTC
94
Drug
Tier
Requirements
/ Limits
ACA; OTC
ACA; OTC
Drug Name
Drug
Tier
prenaissance next
1
prenaissance plus
1
PRENATA
3
prenatabs fa
1
prenatabs rx
1
prenatal
0
PRENATAL + DHA
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
PRENATE MINI
(FERR ASP
GLYCIN)
3
PRENATE PIXIE
3
PRENATE
RESTORE
3
ACA; OTC
PRENATE STAR
3
3
OTC
preplus
1
prenatal complete
0
ACA; OTC
PREQUE 10
3
prenatal formula
0
ACA; OTC
pretab
1
prenatal multi-dha
(algal oil)
0
ACA; OTC
PROFERRINFORTE
3
prenatal one daily
0
ACA; OTC
PROTECT IRON
3
prenatal plus
1
PROVIDA DHA
3
prenatal plus
(calcium carb)
1
PROVIDA OB
3
PURALOR CI
3
prenatal vit#96ferrous fum-fa
0
ACA; OTC
PUREFE OB PLUS
3
prenatal vitamin
0
ACA; OTC
PUREFE PLUS
3
prenatal vitamin
plus low iron
1
purevit dualfe plus
1
3
prenatal-u
1
QUFLORA
PEDIATRIC
PRENATE AM
3
3
PRENATE
CHEWABLE
3
QUFLORA
PEDIATRIC
DROPS
relnate dha
1
PRENATE DHA
(FERR ASP
GLYCIN)
3
renal caps
1
RENAL VITAMIN
3
OTC
PRENATE ELITE
(IRON ASP GLYC)
3
rena-vite
0
ACA; OTC
rena-vite rx
1
PRENATE
ENHANCE
3
reno caps
1
PRENATE
ESSENTIAL(IRONASP-GL)
3
REVESTA
3
3
OTC
PRENATE MINI
3
RIGHT STEP
PRENATAL
VITAMINS
risacal-d
0
ACA; OTC
95
Drug Name
Drug
Tier
R-NATAL OB
3
rulavite dha
1
SELECT-OB
3
SELECT-OB +
DHA
3
se-natal 19
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
taron-prex prenataldha
1
TEXAVITE LQ
3
THRIVITE RX
3
thrivite-19
1
1
tl gard rx
1
se-natal 19 (with
docusate)
1
tl g-fol os
1
tl icon
1
se-tan dha
1
tl-hem 150
1
se-tan plus
1
TRICARE
2
sodium fluoride oral
drops
0
ACA
3
mg fluorid (0.55
mg), 0.5 mg fluoride
(1.1 mg)
0
ACA
TRICARE
PRENATAL DHA
ONE
TRICARE
PRENATAL WITH
DHA
3
tablet,chewable 1
1
tricon
1
TRIFERIC
3
trigels-f forte
1
SOFTGELS
MULTIVITA,B,D,E,K,ZN
3
trinatal gt
1
trinatal rx 1
1
stress formula
0
ACA; OTC
trinate
1
stress formula with
iron
0
ACA; OTC
triphrocaps
1
TRISTART DHA
3
stress formula with
iron(sulf)
0
tri-tabs dha
1
STROVITE FORTE
3
triveen-duo dha
1
STROVITE ONE
3
TRI-VI-FLOR
3
SUPERVITE
3
tri-vit with fluoride
and iron
0
ACA
SUPERVITE (EC)
3
0
ACA
TANDEM PLUS
3
tri-vitamin with
fluoride
taron forte
1
trust natal dha
1
taron-c dha
1
UDAMIN SP
3
ultimatecare one
1
ACA; OTC
96
PA
PA
Drug Name
Drug
Tier
ultimatecare one nf
1
v-c forte
1
vemavite-prx-2
1
VENOFER
3
vic-forte
Requirements
/ Limits
Drug Name
Drug
Tier
Requirements
/ Limits
VITAFOL FE+
(WITH
DOCUSATE)
3
VITAFOL
GUMMIES
3
1
VITAFOL NANO
3
vinate care
1
VITAFOL ULTRA
3
vinate dha
1
vitafol-ob
1
VINATE DHA RF
3
3
vinate ii
1
VITAFOLOB+DHA
vinate m
1
VITAFOL-ONE
3
vinate one
1
VITAL-D RX
3
vinate ultra
1
VITAMED MD
ONE RX
3
virt-advance
1
1
VITAMED MD
PLUS RX
3
virt-c dha
VIRT-CAPS
3
3
virt-gard
1
VITAMEDMD
REDICHEW RX
virt-nate
1
vitamin d3
0
ACA; OTC
virt-nate dha
1
vitamins a,c,d and
fluoride
0
ACA
virt-pn
1
VITAPEARL
3
virt-pn dha
1
VITA-RESPA
3
virt-pn plus
1
VIVA DHA
3
VIRTPREX
3
vol-care rx
1
virt-select
1
vol-nate
1
virt-vite
1
vol-plus
1
virt-vite gt
1
vol-tab rx
1
VIRT-VITE PLUS
3
vp-ch plus
1
vit 3
1
vp-ch-pnv
1
vit b complex-folic
acid
0
ACA; OTC
vp-ggr-b6
1
VITA-BEE WITH C
3
OTC
vp-heme ob
1
VITAFOL
3
vp-heme one
1
VP-PNV-DHA
3
PA
97
Drug Name
Drug
Tier
vp-vite rx
1
XYZBAC
3
zatean-ch
1
zatean-pn dha
1
zatean-pn plus
1
zavara
1
zingiber
1
Requirements
/ Limits
98
Index
1
1ST TIER UNIFINE PENTIPS
.......................................... 50
1ST TIER UNILET
COMFORTOUCH ........... 50
8
8-MOP .................................. 37
A
abacavir .................................. 2
abacavir-lamivudinezidovudine .......................... 2
ABELCET .............................. 2
ABILIFY .............................. 23
ABILIFY MAINTENA ........ 23
ABRAXANE........................ 10
ABSORICA.......................... 38
ABSTRAL............................ 19
acamprosate .......................... 44
ACANYA ............................. 38
acarbose ................................ 62
ACCOLATE......................... 85
ACCU-CHEK AVIVA
CONNECT METER ........ 50
ACCU-CHEK AVIVA PLUS
METER ............................ 51
ACCU-CHEK AVIVA PLUS
TEST STRP ...................... 47
ACCU-CHEK COMBO
SYSTEM .......................... 51
ACCU-CHEK COMPACT
TEST ................................ 47
ACCU-CHEK FASTCLIX .. 51
ACCU-CHEK NANO .......... 51
ACCU-CHEK SAFE-T-PRO
.......................................... 51
ACCU-CHEK SMARTVIEW
TEST STRIP .................... 47
ACCU-CHEK SOFTCLIX
LANCET DEV ................. 51
ACCU-CHEK SOFTCLIX
LANCETS ........................ 51
ACCUPRIL .......................... 28
ACCURETIC ....................... 28
ACCUTREND GLUCOSE .. 47
acebutolol ............................. 28
ACEON ................................ 28
acetaminophen-codeine ........ 19
acetasol hc ............................ 46
acetazolamide ....................... 82
acetazolamide sodium .......... 82
acetic acid ....................... 44, 46
acetic acid-aluminum acetate46
acetylcysteine ....................... 85
ACIPHEX ............................. 68
ACIPHEX SPRINKLE......... 68
acitretin ................................. 35
ACTEMRA .......................... 73
ACTHAR H.P. ..................... 46
ACTHIB (PF) ....................... 71
ACTHREL............................ 61
ACTICLATE .......................... 9
ACTIGALL .......................... 65
ACTI-LANCE LANCETS ... 51
ACTIMMUNE ..................... 71
ACTIQ .................................. 19
ACTIVE FE .......................... 90
ACTIVE OB ......................... 90
ACTIVELLA........................ 74
ACTONEL ..................... 44, 73
ACTOPLUS MET ................ 62
ACTOPLUS MET XR ......... 63
ACTOS ................................. 63
acuicyn.................................. 81
ACULAR.............................. 81
ACULAR LS ........................ 81
ACUVAIL (PF) .................... 81
acyclovir ........................... 2, 41
acyclovir sodium .................... 2
ACZONE .............................. 38
ADACEL(TDAP
ADOLESN/ADULT)(PF) 71
ADAGEN ............................. 44
ADALAT CC ....................... 28
adapalene .............................. 38
ADASUVE ........................... 23
ADCETRIS .......................... 10
ADCIRCA ............................ 85
ADDERALL ........................ 23
ADDERALL XR .................. 23
adefovir ................................... 2
ADEMPAS ........................... 85
ADJUSTABLE LANCING
DEVICE ........................... 51
ADRENACLICK ................. 83
99
adrenalin ............................... 83
adrucil ................................... 10
ADVAIR DISKUS ............... 85
ADVAIR HFA...................... 85
ADVANCED GLUC METER
TEST STRIP ..................... 47
ADVANCED GLUCOSE
METER............................. 51
ADVANCED LANCING
DEVICE ........................... 51
ADVANCED TRAVEL
LANCETS ........................ 51
ADVATE .............................. 32
ADVOCATE BLOOD
GLUCOSE MONITOR .... 51
ADVOCATE LANCET .......51
ADVOCATE PEN NEEDLES
..........................................51
ADVOCATE RAPID-SAFE
LANCING ........................51
ADVOCATE REDI-CODE.. 47
ADVOCATE REDI-CODE
GLU MONITOR .............. 51
ADVOCATE TEST STRIPS47
ADZENYS XR-ODT ........... 23
AEROSPAN ......................... 85
afeditab cr ............................. 28
AFINITOR ........................... 10
AFINITOR DISPERZ .......... 10
AFREZZA ............................ 60
AFSTYLA ............................ 32
AFTERA............................... 76
AGAMATRIX AMP GLUC
MONITOR SYS ............... 51
AGAMATRIX AMP TEST
STRIPS ............................. 47
AGGRENOX ........................ 32
AGRYLIN ............................ 44
AKTEN (PF) ........................ 81
AKYNZEO ........................... 65
ala-cort .................................. 41
ALA-SCALP ........................ 41
ALBENZA ............................. 5
albuterol sulfate .................... 85
ALCAINE............................. 81
alclometasone ....................... 41
ALDACTAZIDE .................. 28
ALDACTONE ..................... 28
ALDARA ............................. 71
ALDURAZYME .................. 61
ALECENSA ......................... 10
alendronate ..................... 44, 73
ALEVICYN ANTIPRURITIC
.......................................... 37
ALFERON N........................ 71
alfuzosin ............................... 87
ALIMTA .............................. 10
ALINIA .................................. 5
ALKERAN ........................... 10
allopurinol ............................ 73
ALLZITAL........................... 19
almotriptan malate ................ 17
ALOCRIL............................. 81
ALOMIDE ........................... 81
aloprim ................................. 73
ALORA ................................ 74
alosetron ............................... 65
ALOXI ................................. 65
ALPHAGAN P ..................... 83
ALPHANATE ...................... 32
ALPHANINE SD ................. 32
alprazolam ............................ 23
alprazolam intensol .............. 23
alprostadil ............................. 87
ALREX................................. 82
ALSUMA ............................. 17
ALTABAX ........................... 41
altacaine ................................ 81
ALTACE .............................. 28
altafluor ................................ 81
altavera (28).......................... 76
ALTERNATE SITE LANCET
.......................................... 51
ALTERNATE SITE
LANCING DEVICE ........ 51
ALTOPREV ......................... 33
ALUVEA ............................. 37
ALVESCO ........................... 85
alyacen 1/35 (28) .................. 76
alyacen 7/7/7 (28) ................. 76
amantadine hcl........................ 2
AMARYL............................. 63
AMBIEN .............................. 23
AMBIEN CR ........................ 23
AMBISOME .......................... 2
amcinonide ........................... 42
AMERGE ............................. 17
amethia ................................. 76
amethia lo ............................. 76
amethyst................................ 76
AMICAR .............................. 32
amifostine crystalline ........... 10
amikacin ................................. 5
amiloride............................... 28
amiloride-hydrochlorothiazide
.......................................... 28
aminocaproic acid................. 32
amiodarone ........................... 27
AMITIZA ............................. 65
amitriptyline ......................... 23
amitriptyline-chlordiazepoxide
.......................................... 23
amlodipine ............................ 28
amlodipine-atorvastatin ........ 33
amlodipine-benazepril .......... 28
amlodipine-valsartan ............ 28
amlodipine-valsartan-hcthiazid
.......................................... 28
AMMONIUM CHLORIDE . 88
ammonium lactate ................ 37
amoxapine ............................ 23
amoxicil-clarithromy-lansopraz
.......................................... 68
amoxicillin .............................. 7
AMOXICILLIN ..................... 7
amoxicillin-pot clavulanate .... 7
AMPHADASE ..................... 44
amphotericin b ........................ 2
ampicillin ................................ 7
ampicillin sodium ................... 7
ampicillin-sulbactam .............. 8
AMPYRA ............................. 18
AMRIX ................................. 18
ANADROL-50 ..................... 61
ANAFRANIL ....................... 23
anagrelide ............................. 44
ANA-LEX KIT..................... 65
ANALPRAM E .................... 65
ANALPRAM-HC ................. 65
ANALPRAM-HC SINGLES65
ANAPROX DS..................... 22
anaspaz ................................. 64
anastrozole ............................ 10
ANCOBON ............................ 2
ANDRODERM .................... 61
100
ANDROGEL ........................ 61
ANDROID ............................ 61
androxy ................................. 61
ANGELIQ ............................ 74
ANIMI-3 WITH VITAMIN D
.......................................... 90
ANORO ELLIPTA ............... 85
ANTABUSE ......................... 44
ANTARA ............................. 33
ANTIVERT .......................... 65
anucort-hc ............................. 65
ANUSOL-HC ....................... 65
ANZEMET ........................... 65
apexicon e ............................. 42
APIDRA ............................... 60
APIDRA SOLOSTAR..........60
APLENZIN...........................23
APOKYN ............................. 16
apraclonidine ........................ 83
apri ........................................ 76
APRISO ................................ 65
APTENSIO XR .................... 23
APTIOM ............................... 14
APTIVUS ............................... 2
AQUA GLYCOLIC HC ....... 42
AQUA LANCE LANCING
DEVICE ........................... 51
ARALAST NP...................... 44
aranelle (28) .......................... 76
ARANESP (IN
POLYSORBATE) ............ 70
ARAVA ................................ 73
arbinoxa ................................ 83
ARCALYST ......................... 71
ARCAPTA NEOHALER ..... 85
ARGATROBAN .................. 32
ARGATROBAN IN 0.9 %
SOD CHLOR.................... 32
ARGATROBAN IN NACL
(ISO-OS)........................... 32
ARICEPT ............................. 18
ARIMIDEX .......................... 10
aripiprazole ........................... 23
ARISTADA .......................... 23
ARIXTRA ............................ 32
armodafinil ........................... 23
ARMOUR THYROID..........64
ARNUITY ELLIPTA ........... 85
AROMASIN ......................... 10
ARRANON .......................... 10
ARTHROTEC 50 ................. 22
ARTHROTEC 75 ................. 22
ARZERRA ........................... 10
ASACOL HD ....................... 65
ascomp with codeine ............ 19
ashlyna .................................. 76
ASMANEX HFA ................. 85
ASMANEX TWISTHALER 85
aspirin-dipyridamole ............ 32
ASSURE 4 STRIPS ............. 47
ASSURE LANCE ................ 51
ASSURE LANCE PLUS ..... 51
ASSURE PLATINUM ... 47, 51
ASSURE PRISM MULTI
METER ............................ 51
ASSURE PRISM MULTI
STRIP ............................... 47
ASTAGRAF XL .................. 10
ASTEPRO ............................ 45
ASTRAMORPH-PF ............. 19
ATABEX EC........................ 90
ATACAND .......................... 28
ATACAND HCT ................. 28
ATELVIA............................. 73
atenolol ................................. 28
atenolol-chlorthalidone......... 28
ATGAM ............................... 71
ATIVAN............................... 23
ATOPICLAIR ...................... 37
atorvastatin ........................... 34
atovaquone ............................. 5
atovaquone-proguanil ............. 5
ATRALIN ............................ 38
ATRAPRO CP ..................... 37
ATRAPRO HYDROGEL .... 37
ATRIPLA ............................... 2
ATROPEN ........................... 43
atropine ........................... 64, 80
ATROVENT HFA ............... 85
AUBAGIO ........................... 70
aubra ..................................... 76
AUGMENTIN ........................ 8
AUGMENTIN ES-600........... 8
AUGMENTIN XR ................. 8
AURYXIA ........................... 65
AUTOJECT 2 INJECTION
DEVICE ........................... 51
AUTO-LANCET MINI........ 51
AUTOLET IMPRESSION
LANC DEV ...................... 51
AUTOLET LANCING
DEVICE ........................... 51
AUTOPEN 2 TO 32 UNITS 51
AVALIDE ............................ 28
AVANDIA ........................... 63
AVAPRO.............................. 28
avar ....................................... 38
AVAR ................................... 38
AVAR LS ............................. 38
AVAR-E GREEN................. 38
AVAR-E LS ......................... 38
AVASTIN ............................ 10
AVC VAGINAL .................. 75
AVEED ................................ 61
AVELOX................................ 8
AVELOX ABC PACK........... 8
AVELOX IN NACL (ISOOSMOTIC) ......................... 8
AVENOVA .......................... 81
aviane.................................... 76
avidoxy ................................... 9
AVIDOXY DK....................... 9
avita ...................................... 38
avo cream ............................. 37
AVODART .......................... 87
AVONEX ............................. 70
AVONEX (WITH ALBUMIN)
.......................................... 70
AVYCAZ ............................... 4
AXERT................................. 17
AXIRON .............................. 61
AYGESTIN .......................... 74
azacitidine............................. 10
AZACTAM ............................ 5
AZACTAM IN DEXTROSE
(ISO-OSM) ......................... 5
AZASAN .............................. 10
AZASITE ............................. 79
azathioprine .......................... 10
azathioprine sodium ............. 10
azelastine ........................ 45, 81
AZELEX .............................. 38
AZILECT ............................. 16
azithromycin ........................... 5
AZOPT ................................. 82
AZOR ................................... 28
aztreonam ............................... 5
101
AZULFIDINE ...................... 65
AZULFIDINE EN-TABS .... 65
azuphen mb ........................... 88
azurette (28) .......................... 76
B
b complex 100 ...................... 90
b complex-vitamin b12 ......... 90
b complex-vitamin c-folic acid
.......................................... 90
baciim ..................................... 5
bacitracin .......................... 5, 79
bacitracin-polymyxin b ......... 79
baclofen ................................ 18
BACMIN .............................. 90
BACTRIM .............................. 9
BACTRIM DS ........................ 9
BACTROBAN NASAL ....... 45
balanced b-100 complex ....... 90
bal-care dha .......................... 90
BAL-CARE DHA
ESSENTIAL ..................... 90
balsalazide ............................ 65
balziva (28) ........................... 76
BANZEL .............................. 14
BARACLUDE ........................ 2
BCG VACCINE, LIVE (PF) 71
b-complex with vitamin c ..... 90
BD AUTOSHIELD PEN
NEEDLE........................... 51
BD CURVED TONSIL
REUSABLE ..................... 51
BD ECLIPSE ........................ 51
BD FILTER NEEDLE-5
MICRON .......................... 52
BD INSULIN PEN NEEDLE
UF SHORT ....................... 52
BD INTEGRA NEEDLE ..... 52
BD LANCET DEVICE ........ 52
BD MICROTAINER
LANCET .......................... 52
BD NOKOR ADMIX
NEEDLE........................... 52
BD PRECISIONGLIDE ....... 52
BD PRECISIONGLIDE NONSTERILE .......................... 52
bd pre-filled normal saline.... 44
BD QUINCKE SPINAL
NEEDLE........................... 52
BD SAFETYGLIDE NEEDLE
.......................................... 52
BD SPECIALTY USE
NEEDLES ........................ 52
BD ULTRA FINE LANCETS
.......................................... 52
BD ULTRA-FINE NANO
PEN NEEDLES................ 52
BD WHITACRE SPINAL
NEEDLE .......................... 52
BD YALE REUSABLE REG
METAL ............................ 52
BEBULIN............................. 32
BECONASE AQ .................. 85
bekyree (28).......................... 76
BELBUCA ........................... 19
BELEODAQ ........................ 10
belladonna alkaloids-opium . 64
belladonna-opium ................. 64
BELSOMRA ........................ 23
benazepril ............................. 28
benazepril-hydrochlorothiazide
.......................................... 28
BENDEKA ........................... 10
BENEFIX ............................. 32
BENICAR ............................ 28
BENICAR HCT ................... 28
BENLYSTA ......................... 73
BENSAL HP ........................ 36
BENTYL .............................. 64
BENZACLIN ....................... 38
BENZACLIN PUMP ........... 38
BENZAMYCIN ................... 38
BENZAMYCINPAK ........... 38
BENZEFOAM ..................... 38
BENZEFOAM ULTRA ....... 39
benzepro ............................... 39
BENZEPRO
(MICROSPHERES) ......... 39
benzonatate ........................... 84
benzoyl peroxide .................. 39
benztropine ........................... 16
BEPREVE ............................ 81
BERINERT .......................... 85
BESIVANCE ....................... 79
BETADINE OPHTHALMIC
PREP ................................ 80
BETAGAN ........................... 80
betamethasone dipropionate . 42
betamethasone valerate......... 42
betamethasone, augmented ... 42
BETAPACE ......................... 27
BETAPACE AF ................... 27
BETASERON ...................... 70
betaxolol ......................... 28, 80
bethanechol chloride............. 87
BETHKIS ............................... 5
BETIMOL ............................ 80
BETOPTIC S ........................ 80
BEVESPI AEROSPHERE ... 85
bexarotene ............................ 10
BEXSERO (PF) .................... 71
BEYAZ................................. 76
BG-STAR ............................. 47
BIAFINE EMULSION......... 37
BIAXIN .................................. 5
bicalutamide ......................... 10
BICILLIN C-R ....................... 8
BICILLIN L-A ....................... 8
BICNU.................................. 10
BIDIL ................................... 28
BIFERA RX ......................... 90
BILTRICIDE .......................... 5
BINOSTO ............................. 73
BIONIME RIGHTEST
GM300 SYSTEM ............. 52
BIONIME RIGHTEST TEST
STRIPS ............................. 47
bisacodyl ............................... 65
bisoprolol fumarate............... 28
bisoprolol-hydrochlorothiazide
.......................................... 28
BIVIGAM ............................ 71
bleomycin ............................. 10
BLEPH-10 ............................ 83
BLEPHAMIDE .................... 83
BLEPHAMIDE S.O.P. ......... 83
BLINCYTO .......................... 10
blisovi 24 fe .......................... 76
blisovi fe 1.5/30 (28) ............ 76
blisovi fe 1/20 (28) ............... 76
BLOOD GLUCOSE TEST .. 47
BLOOD-GLUCOSE METER
.......................................... 52
BLUNT NEEDLE,
DISPOSABLE .................. 52
BONIVA .............................. 73
BOOSTRIX TDAP............... 71
102
BOSULIF ............................. 11
bp 10-1 .................................. 39
bp-50% urea.......................... 37
bpo ........................................ 39
BRAVELLE ......................... 61
BREEZE 2 TEST STRIPS ... 47
BREO ELLIPTA .................. 85
BREVIBLOC ....................... 28
BREVIBLOC IN NACL (ISOOSM) ................................ 28
BREVICON (28) .................. 76
briellyn .................................. 76
BRILINTA ........................... 32
brimonidine........................... 83
BRISDELLE......................... 23
BRIVIACT ........................... 14
BROMFED DM ................... 84
bromfenac ............................. 81
bromocriptine ....................... 16
brompheniramine-pseudoephdm ..................................... 84
BROVANA .......................... 85
BUCALSEP .......................... 40
budesonide ...................... 65, 85
BULLSEYE MINI SAFETY
LANCETS ........................ 52
bumetanide ........................... 28
BUNAVAIL ......................... 22
BUPAP ................................. 19
BUPHENYL ......................... 44
BUPRENEX ......................... 19
buprenorphine hcl ................. 19
buprenorphine-naloxone ....... 22
bupropion hcl ........................ 24
buspirone .............................. 24
BUSULFEX ......................... 11
butalbital compound w/codeine
.......................................... 19
butalbital-acetaminop-caf-cod
.......................................... 19
butalbital-acetaminophen ..... 19
butalbital-acetaminophen-caff
.......................................... 19
butalbital-aspirin-caffeine..... 19
BUTISOL ............................. 24
butorphanol tartrate .............. 22
BUTRANS ........................... 19
BYDUREON ........................ 63
BYETTA .............................. 63
BYSTOLIC .......................... 28
C
cabergoline ........................... 61
CABOMETYX..................... 11
CADEAU DHA.................... 90
CADUET.............................. 34
CAFERGOT ......................... 17
caffeine citrated .................... 44
CALAN ................................ 28
CALAN SR .......................... 28
calcipotriene ......................... 35
calcipotriene-betamethasone 35
calcitonin (salmon) ............... 61
calcitrene .............................. 35
calcitriol .......................... 35, 61
calcium 500 with d ............... 88
calcium acetate ..................... 65
calcium carb and citrate-vitd3
.......................................... 88
calcium citrate + d ................ 89
calcium citrate-vitamin d2.... 89
calcium pnv .......................... 90
calcium-folic acid-vitamin d 90
CALDOLOR ........................ 22
CAMBIA .............................. 22
camila ................................... 74
CAMPATH .......................... 11
CAMPTOSAR ..................... 11
camrese ................................. 76
camrese lo............................. 76
CANASA ............................. 65
CANCIDAS ........................... 2
candesartan ........................... 28
candesartan-hydrochlorothiazid
.......................................... 28
capacet .................................. 19
CAPASTAT ........................... 5
CAPCOF .............................. 84
capecitabine .......................... 11
CAPEX ................................. 42
CAPITAL WITH CODEINE
.......................................... 19
CAPRELSA ......................... 11
captopril ................................ 28
captopril-hydrochlorothiazide
.......................................... 28
CARAC ................................ 37
carafate ................................. 68
CARAFATE ......................... 68
CARBAGLU ........................ 44
carbamazepine ...................... 14
CARBATROL ...................... 14
carbidopa .............................. 16
carbidopa-levodopa .............. 16
carbidopa-levodopaentacapone ........................ 16
carbinoxamine maleate ......... 83
carboplatin ............................ 11
CARDENE IV ...................... 28
CARDENE IV IN
DEXTROSE ..................... 28
CARDENE IV IN SODIUM
CHLORIDE ...................... 28
CARDIOTEK-RX
(BIOPERINE) .................. 90
CARDIZEM ......................... 28
CARDIZEM CD................... 28
CARDIZEM LA ................... 28
CARDURA .......................... 29
CARDURA XL .................... 29
CAREFINE PEN NEEDLE . 52
CAREONE THIN LANCET 52
CARESENS N...................... 52
CARESENS N TEST STRIPS
.......................................... 48
CARESENS N VOICE ........ 52
CARIMUNE NF
NANOFILTERED............ 71
carisoprodol .......................... 18
carisoprodol-asa-codeine ...... 18
carisoprodol-aspirin .............. 18
CARNITOR.......................... 44
CARNITOR (SUGAR-FREE)
.......................................... 44
carteolol ................................ 80
carvedilol .............................. 29
CASODEX ........................... 11
CATAPRES.......................... 29
CATAPRES-TTS-1 .............. 29
CATAPRES-TTS-2 .............. 29
CATAPRES-TTS-3 .............. 29
CAYA CONTOURED ......... 74
CAYSTON ............................. 5
caziant (28) ........................... 77
CEDAX .................................. 4
cefaclor ................................... 4
cefadroxil ................................ 4
cefazolin ................................. 4
103
cefazolin in dextrose (iso-os)..4
CEFAZOLIN IN DEXTROSE
(ISO-OS)............................. 4
cefdinir .................................... 4
cefditoren pivoxil.................... 4
cefepime ................................. 4
CEFEPIME IN DEXTROSE 5
% ......................................... 4
cefepime in dextrose,iso-osm . 4
cefixime .................................. 4
CEFOTAN .............................. 4
cefotaxime .............................. 4
cefotetan ................................. 4
CEFOTETAN IN
DEXTROSE, ISO-OSM ..... 4
cefoxitin .................................. 4
cefoxitin in dextrose, iso-osm.4
cefpodoxime ...........................4
cefprozil ..................................4
ceftazidime .............................4
CEFTAZIDIME IN D5W....... 4
ceftibuten ................................ 4
CEFTIN .................................. 4
ceftriaxone .............................. 4
CEFTRIAXONE .................... 4
ceftriaxone in dextrose,iso-os . 4
cefuroxime axetil .................... 4
cefuroxime sodium ................. 4
CELEBREX ......................... 22
celecoxib ............................... 22
CELEXA .............................. 24
CELLCEPT .......................... 11
CELLCEPT INTRAVENOUS
.......................................... 11
CELONTIN .......................... 14
cem-urea ............................... 37
CENTANY ........................... 41
CENTANY AT ..................... 41
centergy ................................ 84
centratex ............................... 90
cephalexin ............................... 4
CEPROTIN (BLUE BAR) ... 32
CEPROTIN (GREEN BAR) 32
CERDELGA ......................... 61
CEREBYX ........................... 14
CEREZYME......................... 61
CERVARIX VACCINE (PF)
.......................................... 71
CERVIDIL ........................... 75
CESAMET ........................... 65
cetirizine ............................... 83
CETRAXAL......................... 46
CETROTIDE........................ 61
cevimeline ............................ 44
CHANTIX ............................ 45
CHANTIX CONTINUING
MONTH BOX .................. 45
CHANTIX STARTING
MONTH BOX .................. 45
chateal................................... 77
CHEMET ............................. 44
CHENODAL ........................ 65
cheratussin ac ....................... 84
cheratussin dac ..................... 84
chewable multivit-a,b,d,e,k,zn
.......................................... 90
CHILDREN'S NASACORT 85
chloramphenicol sod succinate
............................................ 5
chlordiazepoxide hcl ............ 24
chlordiazepoxide-clidinium .. 64
chlorhexidine gluconate ....... 45
chloroquine phosphate............ 5
chlorothiazide ....................... 29
chlorothiazide sodium .......... 29
chlorpromazine ..................... 24
chlorpropamide..................... 63
chlorthalidone ....................... 29
chlorzoxazone....................... 18
CHOLBAM .......................... 65
cholestyramine (with sugar) . 34
cholestyramine light ............. 34
choline,magnesium salicylate
.......................................... 22
chorionic gonadotropin, human
.......................................... 61
CIALIS ................................. 87
ciclodan ................................ 41
ciclopirox.............................. 41
ciclopirox-ure-camph-mentheuc .................................... 41
cidofovir ................................. 2
ciferex ................................... 90
cilostazol............................... 32
CILOXAN ............................ 80
cimetidine ............................. 69
cimetidine hcl ....................... 69
CIMZIA ................................ 65
CIMZIA POWDER FOR
RECONST ........................ 65
CINQAIR ............................. 85
CINRYZE ............................. 85
CIPRO .................................... 8
CIPRO HC ............................ 46
CIPRO IN D5W ..................... 8
CIPRO XR .............................. 8
CIPRODEX .......................... 46
ciprofloxacin ........................... 8
ciprofloxacin (mixture)........... 8
ciprofloxacin hcl ......... 8, 46, 80
ciprofloxacin in 5 % dextrose . 8
ciprofloxacin lactate ............... 8
cisplatin ................................ 11
citalopram ............................. 24
CITRANATAL (DUALIRON) ............................... 90
CITRANATAL 90 DHA
(ALGAL OIL) .................. 90
CITRANATAL ASSURE .... 90
CITRANATAL B-CALM (FE
GLUC) .............................. 90
CITRANATAL DHA
(ALGAL OIL) .................. 90
CITRANATAL HARMONY
(IRON FUM) .................... 90
citrate of magnesia................ 65
cladribine .............................. 11
claravis.................................. 39
CLARINEX .......................... 83
CLARINEX-D 12 HOUR .... 84
clarithromycin ........................ 5
classic prenatal ..................... 90
cleansing wash ...................... 39
clemastine ............................. 83
CLEOCIN ..................... 5, 6, 75
CLEOCIN IN 5 %
DEXTROSE ....................... 5
CLEOCIN T ......................... 39
CLEVER CHEK BLOOD
GLUCOSE........................ 52
CLEVER CHEK LANCETS 52
CLEVER CHOICE
CLEVER CHOICE MICRO 52
CLEVER CHOICE MICRO
TEST STRIP..................... 48
CLEVER CHOICE PRO 48, 52
104
CLEVER CHOICE TEST
STRIPS ............................. 48
CLEVER CHOICE VOICE+
TEST................................. 48
CLEVIPREX ........................ 29
CLICKFINE ......................... 52
CLIMARA ............................ 74
CLIMARA PRO ................... 74
CLIN SINGLE USE ............... 6
CLINDACIN ETZ ................39
clindacin p ............................ 39
CLINDACIN PAC ............... 39
CLINDAGEL ....................... 39
clindamycin hcl ...................... 6
clindamycin in 5 % dextrose .. 6
clindamycin palmitate hcl....... 6
clindamycin pediatric ............. 6
clindamycin phosphate .... 6, 39,
76
clindamycin-benzoyl peroxide
.......................................... 39
CLINDESSE......................... 76
CLINPRO 5000 .................... 45
clobetasol .............................. 42
clobetasol-emollient ............. 42
CLOBEX .............................. 42
CLOCORTOLONE
PIVALATE....................... 42
clodan ................................... 42
CLODERM........................... 42
CLOLAR .............................. 11
clomiphene citrate ................ 61
clomipramine ........................ 24
clonazepam ........................... 14
clonidine ............................... 29
clonidine hcl ................... 24, 29
clopidogrel ............................ 32
clorazepate dipotassium........24
clorpres .................................29
CLORPRES ..........................29
clotrimazole ...................... 2, 41
clotrimazole-betamethasone . 41
clozapine ............................... 24
CLOZAPINE ........................ 24
CLOZARIL .......................... 24
c-nate dha.............................. 90
CNL 8 NAIL......................... 41
COAGUCHEK LANCETS ..52
COAL TAR .......................... 35
COARTEM ............................ 6
codeine sulfate ...................... 19
codeine-butalbital-asa-caff ... 19
codeine-guaifenesin.............. 84
COGENTIN ......................... 16
COLAZAL ........................... 65
COLCHICINE...................... 73
colchicine-probenecid .......... 73
COLCRYS ........................... 73
COLESTID........................... 34
COLESTID FLAVORED .... 34
colestipol .............................. 34
colistin (colistimethate na) ..... 6
colocort ................................. 65
COLOR LANCETS ............. 52
COLY-MYCIN M
PARENTERAL .................. 6
COLY-MYCIN S ................. 46
COLYTE WITH FLAVOR
PACKS ............................. 65
COMBIGAN ........................ 82
COMBIPATCH.................... 74
COMBIVENT RESPIMAT . 85
COMBIVIR ............................ 2
COMETRIQ ......................... 11
COMFORT EZ PEN
NEEDLES ........................ 52
COMFORT LANCETS ....... 52
COMPAZINE....................... 65
COMPLERA .......................... 2
COMPLETE
FORMULATION D3000 . 90
COMPLETE
FORMULATION
PEDIATRIC ..................... 90
complete natal dha ................ 90
completenate......................... 90
compro.................................. 65
COMTAN............................. 16
CONCEPT DHA .................. 90
CONCEPT OB ..................... 90
CONCEPTROL.................... 76
CONCERTA ........................ 24
CONDYLOX ....................... 37
constulose ............................. 65
CONTOUR LINK ................ 52
CONTOUR NEXT EZ
METER ............................ 52
CONTOUR NEXT METER 53
CONTOUR NEXT STRIPS . 48
CONTOUR NEXT USB
METER ............................ 53
CONTOUR TEST STRIPS .. 48
CONTROL G3 ..................... 48
CONTROL MONITORING
SYSTEM .......................... 53
CONZIP................................ 22
COPAXONE ........................ 70
COPEGUS ............................ 70
CORDRAN .......................... 42
CORDRAN TAPE SMALL
ROLL................................ 42
COREG ................................ 29
COREG CR .......................... 29
CORGARD .......................... 29
CORIFACT .......................... 32
CORLANOR ........................ 35
corlopam ............................... 29
cormax .................................. 42
CORTANE-B ....................... 37
CORTEF............................... 46
CORTENEMA ..................... 65
CORTIFOAM ...................... 65
cortisone ............................... 46
CORTISPORIN .................... 41
CORTROSYN ...................... 46
corvita ................................... 90
corvita 150 ............................ 90
CORVITE ............................. 90
CORVITE 150 ...................... 91
CORVITE FE ....................... 91
CORVITE FREE .................. 91
CORZIDE ............................. 29
COSENTYX......................... 35
COSENTYX (2 SYRINGES)
.......................................... 35
COSENTYX PEN ................ 35
COSENTYX PEN (2 PENS) 35
COSMEGEN ........................ 11
COSOPT............................... 82
COSOPT (PF)....................... 82
cosyntropin ........................... 46
COSYNTROPIN .................. 47
COTELLIC ........................... 11
COUMADIN ........................ 32
covaryx ................................. 74
covaryx h.s............................ 74
COZAAR.............................. 29
105
CREON................................. 65
CRESEMBA........................... 2
CRINONE ............................ 74
CRIXIVAN............................. 2
cromolyn ................... 66, 81, 85
cryselle (28) .......................... 77
CUPRIMINE ........................ 73
CUROSURF .........................85
CUTIVATE ..........................42
CUVPOSA ...........................64
cyanocobalamin (vitamin b-12)
.......................................... 91
cyclafem 1/35 (28) ................ 77
cyclafem 7/7/7 (28)............... 77
CYCLESSA (28) .................. 77
cyclobenzaprine .................... 18
CYCLOGYL ........................ 80
CYCLOMYDRIL ................. 83
cyclopentolate ....................... 80
cyclophosphamide ................ 11
CYCLOSERINE..................... 6
CYCLOSET ......................... 63
cyclosporine .......................... 11
cyclosporine modified .......... 11
CYKLOKAPRON ................ 32
CYMBALTA ........................ 24
cyproheptadine ..................... 83
CYRAMZA .......................... 11
cyred ..................................... 77
CYSTADANE ...................... 66
CYSTAGON ........................ 88
CYSTARAN......................... 81
cytarabine ............................. 11
cytarabine (pf) ...................... 11
CYTOMEL ........................... 64
CYTOTEC ............................ 69
CYTOVENE........................... 2
cytra k crystals ...................... 88
cytra-2 ................................... 88
cytra-3 ................................... 88
cytra-k ................................... 88
D
D.H.E.45 ............................... 17
dacarbazine ........................... 11
DACOGEN........................... 11
DAKLINZA ........................... 2
DALIRESP ........................... 85
DALVANCE .......................... 6
danazol .................................. 61
DANTRIUM ........................ 18
dantrolene ............................. 18
dapsone ................................... 6
DAPTACEL (DTAP
PEDIATRIC) (PF)............ 71
DARAPRIM ........................... 6
darifenacin ............................ 87
DARZALEX ........................ 11
dasetta 1/35 (28) ................... 77
dasetta 7/7/7 (28) .................. 77
daunorubicin ......................... 11
DAYPRO ............................. 22
daysee ................................... 77
DAYTRANA ....................... 24
DDAVP ................................ 61
DEBACTEROL ................... 46
deblitane ............................... 74
decitabine ............................. 11
DELESTROGEN ................. 74
deltasone ............................... 47
delyla (28) ............................ 77
DEMADEX .......................... 29
demeclocycline ....................... 9
DEMEROL........................... 20
demerol (pf) .......................... 19
DEMEROL (PF) ............ 19, 20
DEMSER.............................. 29
DENAVIR ............................ 41
denta 5000 plus..................... 46
dentagel ................................ 46
DEPACON ........................... 15
DEPAKENE ......................... 15
DEPAKOTE ......................... 15
DEPAKOTE ER ................... 15
DEPAKOTE SPRINKLES .. 15
DEPEN TITRATABS .......... 73
DEPO-ESTRADIOL ............ 74
DEPO-PROVERA ............... 74
DEPO-SUBQ PROVERA 104
.......................................... 74
DEPO-TESTOSTERONE.... 61
DERMA-SMOOTHE/FS
BODY OIL ....................... 42
DERMA-SMOOTHE/FS
SCALP OIL ...................... 42
DERMASORB HC
COMPLETE KIT ............. 42
DERMASORB TA
COMPLETE KIT ............. 42
DERMASORB XM
COMPLETE KIT ............. 37
DERMATOP ........................ 42
DERMOTIC OIL ................. 46
DESCOVY ............................. 2
desipramine .......................... 24
desloratadine ......................... 83
desmopressin ........................ 61
desog-e.estradiol/e.estradiol . 77
DESOGEN ........................... 77
desogestrel-ethinyl estradiol . 77
DESONATE ......................... 42
desonide ................................ 42
DESOWEN .......................... 42
desoximetasone .................... 42
DESOXYN ........................... 24
DESVENLAFAXINE .......... 24
DESVENLAFAXINE
FUMARATE .................... 24
DETROL .............................. 87
DETROL LA ........................ 87
dexamethasone ..................... 47
dexamethasone intensol ........ 47
dexamethasone sodium
phosphate .......................... 82
dexedrine .............................. 24
DEXEDRINE SPANSULE .. 24
DEXILANT .......................... 69
dexmethylphenidate.............. 24
DEXPAK 10 DAY ............... 47
DEXPAK 13 DAY ............... 47
DEXPAK 6 DAY ................. 47
dexrazoxane hcl .................... 10
dextroamphetamine .............. 24
dextroamphetamineamphetamine .................... 24
dialyvite ................................ 91
DIALYVITE 3000 ............... 91
DIALYVITE 5000 ............... 91
dialyvite 800 ......................... 91
DIALYVITE 800 WITH IRON
.......................................... 91
DIALYVITE SUPREME D . 91
DIAMOX SEQUELS ........... 82
DIASTAT ............................. 15
DIASTAT ACUDIAL .......... 15
DIATRUE PLUS BLOOD
GLUCOSE MET .............. 53
106
DIATRUE PLUS TEST STRIP
.......................................... 48
diazepam ......................... 15, 24
diazepam intensol ................. 24
DIBENZYLINE ................... 29
DICLEGIS ............................ 66
diclofenac potassium ............22
diclofenac sodium .....22, 37, 81
diclofenac-misoprostol ......... 22
dicloxacillin ............................ 8
dicyclomine .......................... 64
didanosine ............................... 2
DIFFERIN ............................ 39
DIFICID ................................. 5
diflorasone ............................ 42
DIFLUCAN ............................ 2
diflunisal ............................... 22
digitek ................................... 32
digox ..................................... 32
digoxin .................................. 32
dihydrocode-acetaminophencaff ....................................20
dihydrocodeine-aspirin-caff .20
dihydroergotamine ................17
DILANTIN ........................... 15
DILANTIN EXTENDED ..... 15
DILANTIN INFATABS ...... 15
DILANTIN-125 .................... 15
DILATRATE-SR ................. 35
DILAUDID........................... 20
DILAUDID-HP (PF) ............20
diltiazem ............................... 29
dimenhydrinate ..................... 66
DIOVAN .............................. 29
DIOVAN HCT ..................... 29
DIPENTUM ......................... 66
diphenhydramine hcl ............ 83
diphenoxylate-atropine ......... 64
DIPROLENE ........................ 42
DIPROLENE AF .................. 42
dipyridamole ......................... 32
DISALCID ........................... 22
diskets ................................... 20
disopyramide phosphate ....... 27
disulfiram .............................. 44
DITROPAN XL.................... 87
DIURIL................................. 29
DIURIL IV ........................... 29
divalproex ............................. 15
DIVIGEL.............................. 74
DOCEFREZ ......................... 11
docetaxel............................... 11
DOLOPHINE ....................... 20
donepezil .............................. 18
DONNATAL........................ 64
DORAL ................................ 24
DORIBAX.............................. 6
DORYX.................................. 9
DORYX MPC ........................ 9
dorzolamide .......................... 82
dorzolamide-timolol ............. 82
dothelle dha .......................... 91
DOVONEX .......................... 35
doxazosin.............................. 29
doxepin ........................... 24, 37
doxercalciferol ...................... 61
DOXIL ................................. 11
doxorubicin........................... 11
doxorubicin, peg-liposomal .. 11
doxy-100................................. 9
doxycycline hyclate ................ 9
doxycycline monohydrate ...... 9
DOXYCYCLINE
MONOHYDRATE............. 9
DRISDOL............................. 91
drithocreme hp...................... 35
dronabinol............................. 66
droperidol ............................. 66
DROPLET LANCETS ......... 53
DROPLET LANCING
DEVICE ........................... 53
DROPLET PEN NEEDLE ... 53
drospirenone-ethinyl estradiol
.......................................... 77
DROXIA .............................. 11
DUAC................................... 39
DUAVEE ............................. 74
DUET DHA BALANCED ... 91
DUET DHA WITH OMEGA-3
.......................................... 91
DUETACT ........................... 63
DUEXIS ............................... 22
DULERA.............................. 85
duloxetine ............................. 24
DUODOTE........................... 43
DUOPA ................................ 17
DURACHOL........................ 91
DURAGESIC ....................... 20
duramorph (pf) ..................... 20
DUREZOL ........................... 82
DURLAZA ........................... 32
dutasteride ............................ 87
dutasteride-tamsulosin .......... 87
DUTOPROL......................... 29
DYANAVEL XR ................. 24
DYAZIDE ............................ 29
DYLOJECT .......................... 22
DYMISTA ............................ 85
DYRENIUM ........................ 29
DYSPORT ............................ 71
E
e.e.s. 400 ................................. 5
E.E.S. GRANULES................ 5
EASY CLICK LANCING
DEVICE ........................... 53
EASY COMFORT LANCETS
.......................................... 53
EASY COMFORT PEN
NEEDLES ........................ 53
EASY MINI EJECT
EASY PLUS II BLOOD
GLUCOSE MET .............. 53
EASY PLUS II TEST........... 48
EASY STEP ......................... 48
EASY STEP BLOOD
GLUCOSE METER ......... 53
EASY TALK BLOOD
EASY TALK GLUCOSE
TEST ................................ 48
EASY TOUCH FLIPLOCK
NEEDLE .......................... 53
EASY TOUCH GLUCOSE
MONITOR ....................... 53
EASY TOUCH
HYPODERMIC NEEDLE
.......................................... 53
EASY TOUCH LANCING
DEVICE ........................... 53
EASY TOUCH TEST STRIP
.......................................... 48
EASY TRAK BLOOD
EASY TRAK GLUCOSE
TEST ................................ 48
107
EASYGLUCO
MONITORING SYSTEM 53
EASYGLUCO PLUS ........... 48
EASYGLUCO TEST ........... 48
EASYMAX .......................... 48
EASYMAX L BLOOD
EASYMAX NG.................... 53
EASYMAX V SPEAKING
GLUCOSE SYS ............... 53
EASYMAX V2 BLOOD
EC-NAPROSYN .................. 22
econazole .............................. 41
econtra ez .............................. 77
ECOZA ................................. 41
EDARBI ............................... 29
EDARBYCLOR ................... 29
EDECRIN .............................29
EDLUAR ..............................24
ed-spaz .................................. 64
EDURANT ............................. 2
eemt ...................................... 74
eemt hs .................................. 74
effer-k ................................... 89
EFFER-K .............................. 89
EFFEXOR XR ...................... 24
EFFIENT .............................. 32
EFUDEX .............................. 37
EGRIFTA ............................. 70
ELAPRASE .......................... 61
ELDEPRYL .......................... 17
ELDERCAPS ....................... 91
ELELYSO ............................ 61
ELEMENT COMPACT
ELEMENT COMPACT TEST
STRIPS ............................. 48
ELEMENT COMPACT V
GLUCOSE MTR .............. 53
ELEMENT PLUS BLOOD
GLUCOSE KIT ................ 53
ELEMENT TEST STRIPS ... 48
ELESTAT ............................. 81
ELESTRIN ........................... 74
eletone................................... 37
ELIDEL ................................ 37
ELIGARD............................. 11
ELIMITE .............................. 43
elinest ................................... 77
eliphos .................................. 66
ELIQUIS .............................. 32
ELITEK ................................ 10
ELIXOPHYLLIN ................. 85
ELLA .................................... 77
ELLENCE ............................ 11
ELMIRON............................ 88
ELOCON.............................. 42
ELOCTATE ......................... 32
EMADINE ........................... 81
EMBEDA ............................. 20
EMBRACE BLOOD
GLUCOSE SYSTEM. 48, 53
EMBRACE EVO TEST
STRIPS ............................. 48
EMBRACE PRO GLUCOSE
METER ............................ 53
EMBRACE PRO TEST
STRIPS ............................. 48
EMCYT ................................ 11
EMEND................................ 66
emoquette ............................. 77
EMPLICITI .......................... 11
EMSAM ............................... 24
EMTRIVA.............................. 2
emulsion sb........................... 37
EMVERM .............................. 6
ENABLEX ........................... 87
enalapril maleate .................. 29
enalaprilat ............................. 29
enalapril-hydrochlorothiazide
.......................................... 29
ENBREL .............................. 73
ENBREL SURECLICK ....... 73
endocet ................................. 20
ENDOMETRIN ................... 74
ENGERIX-B (PF) ................ 71
ENGERIX-B PEDIATRIC
(PF) ................................... 71
ENLITE SYSTEM ............... 53
ENLYTE (FERROUS
GLYCINE) ....................... 91
enoxaparin ............................ 32
enpresse ................................ 77
enskyce ................................. 77
ENSTILAR........................... 35
entacapone ............................ 17
entecavir ................................. 2
ENTOCORT EC................... 66
ENTRESTO.......................... 35
ENTYVIO ............................ 66
enulose .................................. 66
ENVARSUS XR .................. 11
EPANED .............................. 29
EPCLUSA .............................. 2
EPICERAM .......................... 37
EPIDUO ............................... 39
EPIDUO FORTE.................. 39
EPIFOAM ............................ 35
epinastine .............................. 81
epinephrine ........................... 83
EPIPEN 2-PAK .................... 83
EPIPEN JR 2-PAK ............... 83
epirubicin .............................. 11
EPISIL .................................. 46
EPISNAP .............................. 83
epitol ..................................... 15
EPIVIR ................................... 2
EPIVIR HBV .......................... 3
eplerenone ............................ 29
EPOGEN .............................. 70
epoprostenol (glycine) .......... 29
eprosartan ............................. 29
EPZICOM .............................. 3
EQUETRO ........................... 15
ERAXIS(WATER DILUENT)
............................................ 2
ERBITUX ............................. 11
ergocalciferol (vitamin d2) ... 91
ergoloid................................. 24
ERGOMAR .......................... 17
ERIVEDGE .......................... 11
errin ...................................... 74
ERTACZO............................ 41
ERWINAZE ......................... 11
ery pads................................. 39
erygel .................................... 39
ERYPED 200 ......................... 5
ERYPED 400 ......................... 5
ery-tab ..................................... 5
ERY-TAB ............................... 5
ERYTHROCIN ...................... 5
erythrocin (as stearate) ........... 5
erythromycin .................... 5, 80
erythromycin ethylsuccinate... 5
erythromycin with ethanol.... 39
108
erythromycin-benzoyl peroxide
.......................................... 39
ESBRIET .............................. 85
ESCAVITE ........................... 91
ESCAVITE D ....................... 91
ESCAVITE LQ .................... 91
escitalopram oxalate ............. 24
ESGIC................................... 20
esmolol ................................. 29
esomeprazole magnesium ..... 69
esomeprazole sodium ........... 69
estarylla................................. 77
estazolam .............................. 24
ESTRACE ............................ 74
estradiol ................................ 74
estradiol valerate ................... 75
estradiol-norethindrone acet . 75
ESTRING ............................. 75
ESTROGEL.......................... 75
estrogens-methyltestosterone75
estropipate............................. 75
ESTROSTEP FE-28 ............. 77
eszopiclone ........................... 24
ethacrynate sodium ............... 29
ethambutol .............................. 6
ethosuximide......................... 15
ethyl chloride ........................ 40
etidronate disodium .............. 44
etodolac................................. 22
ETOPOPHOS ....................... 11
etoposide ............................... 11
EURAX ................................ 43
EVAMIST ............................ 75
EVEKEO .............................. 24
EVENCARE G2 ............. 48, 53
EVENCARE G3 GLUCOSE
METER............................. 53
EVENCARE G3 TEST ........ 48
EVENCARE MINI
GLUCOSE TEST STR ..... 48
EVISTA ................................ 73
EVOCLIN............................. 39
EVOLUTION BLOOD
EVOLUTION TEST STRIPS
.......................................... 48
EVOMELA........................... 11
EVOTAZ ................................ 3
EVOXAC ............................. 44
EVZIO .................................. 22
EXALGO ER ....................... 20
EXEL HYPODERMIC
NEEDLES ........................ 54
EXELDERM ........................ 41
EXELON .............................. 18
exemestane ........................... 11
EXFORGE ........................... 29
EXFORGE HCT .................. 29
EXJADE ............................... 44
EXODERM .......................... 41
EXPECTA PRENATAL ...... 91
EXTAVIA ............................ 70
EXTINA ............................... 41
EXTRA-VIRT PLUS DHA . 91
EYLEA ................................. 81
e-z ject lancets ...................... 54
EZ SMART LANCETS ....... 54
EZ SMART PLUS SYSTEM
.......................................... 54
EZ SMART PLUS TEST ..... 48
EZ SMART SYSTEM ......... 54
EZ SMART TEST................ 48
F
FA-8 ..................................... 91
fabb ....................................... 91
FABIOR ............................... 39
FABRAZYME ..................... 61
FACTIVE ............................... 8
fallback solo ......................... 77
falmina (28) .......................... 77
famciclovir ............................. 3
famotidine............................. 69
famotidine (pf)...................... 69
famotidine (pf)-nacl (iso-os) 69
FAMVIR ................................ 3
FANAPT .............................. 24
FARESTON ......................... 11
FARXIGA ............................ 63
FARYDAK........................... 11
FASLODEX ......................... 11
FAZACLO ........................... 24
FC2 FEMALE CONDOM ... 74
fe c plus ................................ 91
FEIBA NF ............................ 32
felbamate .............................. 15
FELBATOL ......................... 15
FELDENE ............................ 22
felodipine.............................. 29
fem ph ................................... 76
FEMARA ............................. 11
FEMCAP .............................. 74
FEMCON FE ........................ 77
FEMHRT LOW DOSE ........ 75
FEMRING ............................ 75
fenofibrate ............................ 34
FENOFIBRATE ................... 34
fenofibrate micronized ......... 34
fenofibrate nanocrystallized . 34
fenofibric acid....................... 34
fenofibric acid (choline) ....... 34
FENOGLIDE........................ 34
fenoprofen ............................ 22
fentanyl ................................. 20
FENTANYL ......................... 20
fentanyl citrate ...................... 20
fentanyl citrate (pf) ............... 20
FENTORA............................ 20
FERAHEME ........................ 91
FERIVA 21-7 TABLET ....... 91
FERIVA FA (SUMALATE) 91
ferocon .................................. 91
FERRALET 90 DUAL-IRON
DELIVERY ...................... 91
ferraplus 90 ........................... 91
ferrex 150 forte ..................... 91
ferrex 150 forte plus ............. 91
ferrex 28 ............................... 91
FERRIPROX ........................ 44
FERRLECIT ......................... 44
ferrocite plus ......................... 91
ferrogels forte ....................... 91
FETZIMA ............................. 24
FEXMID ............................... 18
FIBRICOR............................ 34
FIFTY50 SAFETY SEAL
LANCETS ........................ 54
FIFTY50 TEST STRIP ........ 48
FINACEA ............................. 39
finasteride ............................. 87
FINE 30 UNIVERSAL
LANCETS ........................ 54
FINGERSTIX LANCETS.... 54
FIORICET ............................ 20
FIORICET WITH CODEINE
.......................................... 20
FIORINAL ........................... 20
FIORINAL-CODEINE #3 ... 20
109
FIRAZYR ............................. 86
FIRMAGON KIT W
DILUENT SYRINGE ...... 11
FIRST CHOICE LANCETS
THIN.................................54
FLAGYL ................................6
FLAGYL ER ..........................6
FLAREX............................... 82
flavoxate ............................... 87
FLEBOGAMMA DIF .......... 71
flecainide .............................. 27
FLECTOR ............................ 22
FLOLAN .............................. 29
FLOMAX ............................. 87
FLORIVA ............................. 91
FLORIVA (FLUORIDEVITAMIN D3).................. 91
FLORIVA PLUS .................. 91
FLOVENT DISKUS ............ 86
FLOVENT HFA ................... 86
FLOW-EZE VENTED
NEEDLE........................... 54
FLOWTUSS ......................... 84
floxuridine ............................ 11
FLUARIX QUAD 2016-2017
(PF) ...................................71
flucaine .................................81
fluconazole .............................2
fluconazole in dextrose(iso-o) 2
flucytosine .............................. 2
fludarabine ............................ 12
fludrocortisone ...................... 47
FLULAVAL QUAD 20162017 .................................. 71
FLUMADINE......................... 3
flumazenil ............................. 24
flunisolide ............................. 86
fluocinolone .......................... 42
fluocinolone acetonide oil .... 46
fluocinolone and shower cap 42
fluocinonide .......................... 42
fluocinonide-e ....................... 42
FLUORABON ...................... 91
FLUOR-A-DAY ................... 91
fluor-a-day (with xylitol) ...... 91
fluorescein-benoxinate ......... 81
fluorescein-proparacaine ...... 81
fluoridex daily defense ......... 46
FLUORIDEX SENSITIVITY
RELIEF ............................ 46
fluoritab ................................ 92
FLUORITAB ....................... 91
fluorometholone ................... 82
FLUOROPLEX .................... 37
fluorouracil ..................... 12, 37
FLUOROURACIL ............... 37
fluoxetine.............................. 24
FLUOXETINE ..................... 25
fluphenazine decanoate ........ 25
fluphenazine hcl ................... 25
FLURA-DROPS .................. 92
flurandrenolide ..................... 42
flurazepam ............................ 25
flurbiprofen........................... 22
flurbiprofen sodium .............. 81
flurox .................................... 81
flutamide............................... 12
fluticasone ...................... 42, 86
fluvastatin ............................. 34
fluvoxamine.......................... 25
FLUZONE HIGH-DOSE
2016-17 (PF) .................... 71
FLUZONE INTRADERM
QUAD 2016-17 ................ 71
FLUZONE QUAD 2016-2017
.......................................... 71
FLUZONE QUAD 2016-2017
(PF) ................................... 71
FLUZONE QUAD PEDI
2016-17 (PF) .................... 71
FML FORTE ........................ 82
FML LIQUIFILM ................ 82
FML S.O.P. .......................... 82
focalgin 90 dha ..................... 92
focalgin ca ............................ 92
focalgin dss ........................... 92
FOCALIN............................. 25
FOCALIN XR ...................... 25
folbecal ................................. 92
folbee .................................... 92
folbee ar ................................ 92
folbee plus ............................ 92
FOLET DHA ........................ 92
FOLET ONE ........................ 92
FOLGARD OS ..................... 92
FOLGARD RX .................... 92
folic acid ............................... 92
folic acid-vit b6-vit b12 ........ 92
folivane-f .............................. 92
folivane-ob............................ 92
folivane-plus ......................... 92
FOLLISTIM AQ .................. 61
FOLOTYN ........................... 12
folplex 2.2............................. 92
foltabs 800 ............................ 92
FOLTRATE.......................... 92
fondaparinux ......................... 32
FORA D10 ........................... 48
FORA D15G......................... 48
FORA D20 ..................... 48, 54
FORA D40-G31 TEST
STRIPS ............................. 48
FORA G20 ..................... 48, 54
FORA G30A................... 48, 54
FORA GD50 BLOOD
GLUCOSE SYSTEM ....... 54
FORA GD50 TEST STRIPS 48
FORA LANCING DEVICE. 54
FORA TEST N'GO VOICE
METER ............................ 54
FORA TEST STRIP ............. 48
FORA TN'G VOICE METER
.......................................... 54
FORA TN'G VOICE TEST
STRIPS ............................. 48
FORA V10 ..................... 48, 54
FORA V12 BLOOD
FORA V12 GLUCOSE ........ 48
FORA V20 ..................... 48, 54
FORA V30A......................... 54
FORACARE GD20 .............. 49
FORACARE GD20
FORACARE GD40 .............. 49
FORACARE GD40A
FORACARE GD40B
FORACARE LANCETS ...... 54
FORADIL AEROLIZER ..... 86
FORFIVO XL....................... 25
FORTAMET ........................ 63
FORTAVIT .......................... 90
FORTAZ ................................ 4
110
FORTAZ IN DEXTROSE 5 %
............................................ 4
FORTEO............................... 73
FORTESTA .......................... 61
fortical................................... 61
FORTISCARE BLOOD
GLUCOSE SYST ............. 54
FORTISCARE GLUCOSE
TEST STRIPS .................. 49
FOSAMAX...........................73
FOSAMAX PLUS D ............ 73
foscarnet .................................3
FOSCAVIR ............................3
fosinopril............................... 29
fosinopril-hydrochlorothiazide
.......................................... 29
fosphenytoin ......................... 15
FOSRENOL ......................... 66
FRAGMIN ............................ 32
FREESTYLE FLASH
SYSTEM .......................... 54
FREESTYLE FREEDOM .... 54
FREESTYLE FREEDOM
LITE ................................. 54
FREESTYLE INSULINX ...49,
54
FREESTYLE INSULINX
TEST STRIPS .................. 49
FREESTYLE LANCETS ..... 54
FREESTYLE LITE METER 54
FREESTYLE LITE STRIPS 49
FREESTYLE PRECISION
NEO METER ................... 54
FREESTYLE PRECISION
NEO STRIPS .................... 49
FREESTYLE SIDEKICK II. 54
FREESTYLE SYSTEM KIT54
FREESTYLE TEST ............. 49
FREESTYLE UNISTIK 2 .... 55
FROVA................................. 17
frovatriptan ........................... 17
full spectrum b-vitamin c...... 92
FULYZAQ ........................... 64
FURADANTIN ...................... 9
furosemide ............................ 29
FUSION PLUS ..................... 92
FUZEON ................................ 3
fyavolv .................................. 75
FYCOMPA ........................... 15
G
gabapentin ............................ 15
GABITRIL ........................... 15
galantamine .......................... 18
GALZIN ............................... 89
GAMASTAN S/D ................ 71
GAMMAGARD LIQUID .... 72
GAMMAGARD S-D (IGA < 1
MCG/ML) ........................ 72
GAMMAKED ...................... 72
GAMMAPLEX .................... 72
GAMUNEX-C ..................... 72
ganciclovir sodium ................. 3
GANIRELIX ........................ 61
GARDASIL (PF).................. 72
GARDASIL 9 (PF)............... 72
GASTROCROM .................. 66
gatifloxacin ........................... 80
GATTEX 30-VIAL .............. 66
gavilyte-c .............................. 66
gavilyte-g.............................. 66
gavilyte-h and bisacodyl....... 66
gavilyte-n .............................. 66
GAZYVA ............................. 12
GE100 BLOOD GLUCOSE
SYSTEM .......................... 55
GE100 BLOOD GLUCOSE
TEST STRIP .................... 49
GELCLAIR .......................... 46
GELNIQUE .......................... 87
GELX ................................... 46
gemcitabine .......................... 12
gemfibrozil ........................... 34
GEMZAR ............................. 12
GENERESS FE .................... 77
generlac ................................ 66
gengraf .................................. 12
GENOTROPIN .................... 70
GENOTROPIN MINIQUICK
.......................................... 70
GENSTRIP TEST STRIP .... 49
gentak ................................... 80
gentamicin .................. 6, 41, 80
gentamicin in nacl (iso-osm) .. 6
GENTAMICIN IN NACL
(ISO-OSM) ......................... 6
gentamicin sulfate (ped) (pf) .. 6
gentamicin sulfate (pf) ........... 6
GENTAMICIN SULFATE
(PF) ..................................... 6
GENVOYA ............................ 3
GEODON ............................. 25
gianvi (28) ............................ 77
GIAZO.................................. 66
gildagia ................................. 77
gildess 1.5/30 (21) ................ 77
gildess 1/20 (21) ................... 77
gildess 24 fe .......................... 77
gildess fe 1.5/30 (28) ............ 77
gildess fe 1/20 (28) ............... 77
GILENYA ............................ 70
GILOTRIF ............................ 12
GLASSIA ............................. 44
glatopa .................................. 70
GLEEVEC ............................ 12
GLEOSTINE ........................ 12
GLIADEL WAFER .............. 12
glimepiride............................ 63
glipizide ................................ 63
glipizide-metformin .............. 63
GLUCAGEN DIAGNOSTIC
KIT ................................... 50
GLUCAGEN HYPOKIT ..... 50
GLUCAGON EMERGENCY
KIT (HUMAN)................. 50
GLUCAGON HCL............... 50
GLUCO NAVII GLUCOSE
MONITOR ....................... 55
GLUCO NAVII TEST STRIP
.......................................... 49
GLUCOCARD 01 METER.. 55
GLUCOCARD 01 SENSOR
PLUS ................................ 49
GLUCOCARD EXPRESSION
.................................... 49, 55
GLUCOCARD SHINE
METER ............................ 55
GLUCOCARD SHINE TEST
STRIPS ............................. 49
GLUCOCARD VITAL ........ 55
GLUCOCARD VITAL
SENSOR........................... 49
GLUCOCARD VITAL TEST
STRIPS ............................. 49
GLUCOCOM BLOOD
GLUCOSE........................ 55
GLUCOCOM GLUCOSE.... 49
111
GLUCOCOM LANCETS .... 55
GLUCOPHAGE ................... 63
GLUCOPHAGE XR ............ 63
GLUCOTROL ...................... 63
GLUCOTROL XL................63
GLUCOVANCE................... 63
glyburide ............................... 63
glyburide micronized ............ 63
glyburide-metformin............. 63
GLYCOPHOS ...................... 89
glycopyrrolate ....................... 64
glydo ..................................... 40
GLYNASE ........................... 63
GLYSET ............................... 63
GLYXAMBI......................... 63
GM100 ............................ 49, 55
GMATE LANCETS ............. 55
GMATE LANCING DEVICE
.......................................... 55
GMATE SMART METER... 55
GMATE SMART STARTER
.......................................... 55
GMATE TEST STRIPS ....... 49
GMATE VOICE METER .... 55
GOLYTELY ......................... 66
GONAL-F............................. 61
GONAL-F RFF .................... 61
GONAL-F RFF REDI-JECT 61
GORDONS UREA ...............37
GRALISE .............................15
GRALISE 30-DAY STARTER
PACK ............................... 15
granisetron (pf) ..................... 66
granisetron hcl ...................... 66
GRANIX............................... 70
GRASTEK ............................ 72
griseofulvin microsize ............ 2
griseofulvin ultramicrosize ..... 2
GRIS-PEG
(ULTRAMICROSIZE)....... 2
guaifenesin ac ....................... 84
guaifenesin dac ..................... 84
guanfacine....................... 25, 30
guanidine .............................. 25
GYNAZOLE-1 ..................... 76
H
HALAVEN ........................... 12
HALCION ............................ 25
HALDOL .............................. 25
HALDOL DECANOATE .... 25
halobetasol propionate.......... 43
HALOG ................................ 43
haloperidol ............................ 25
haloperidol decanoate ........... 25
haloperidol lactate ................ 25
HAVRIX (PF) ...................... 72
HEALTHPRO GLUCOSE
MONITOR ....................... 55
HEALTHPRO TEST STRIPS
.......................................... 49
HEALTHY ACCENTS
AUTOLET ....................... 55
HEALTHY ACCENTS
UNIFINE PENTIP ........... 55
HEALTHY ACCENTS
UNILET LANCET........... 55
heartburn treatment 24 hour . 69
heather .................................. 75
HECTOROL......................... 61
HELIXATE FS ..................... 32
HEMANGEOL..................... 30
hematinic plus vit/minerals .. 92
hematinic/folic acid .............. 92
hematogen ............................ 92
hematogen fa ........................ 92
hematogen forte .................... 92
HEMATRON ....................... 92
HEMATRON-AF ................. 92
HEMAX ............................... 92
hemenatal ob ........................ 92
hemenatal ob + dha .............. 92
hemetab ................................ 92
hemmorex-hc........................ 66
HEMOCYTE-F .................... 92
HEMOCYTE-PLUS............. 92
HEMOFIL M HIGH............. 32
HEMOFIL M LOW ............. 32
HEMOFIL M MID ............... 32
HEMOFIL M SUPER HIGH32
hep flush-10 (pf) ................... 32
HEPAGAM B ...................... 72
heparin (porcine) .................. 32
heparin (porcine) in 5 % dex 32
heparin (porcine) in nacl (pf) 32
heparin flush ......................... 32
heparin flush(porcine)-0.9nacl
.......................................... 32
heparin lock flush ................. 33
heparin lock flush (porcine) . 33
heparin lockflush(porcine)(pf)
.......................................... 33
heparin(porcine) in 0.45% nacl
.......................................... 33
HEPARIN(PORCINE) IN
0.45% NACL .................... 33
heparin, porcine (pf) ............. 33
HEPSERA .............................. 3
HERCEPTIN ........................ 12
HETLIOZ ............................. 25
HEXALEN ........................... 12
HIPREX.................................. 9
HISTEX-AC ......................... 84
HIZENTRA .......................... 72
homatropaire ......................... 80
homatropine hbr ................... 80
HORIZANT.......................... 18
hpr......................................... 37
hpr plus ................................. 37
hpr plus hydrogel .................. 37
HPR PLUS-MB HYDROGEL
.......................................... 37
huber safety needles (disp.) .. 55
HUMALOG.......................... 60
HUMALOG KWIKPEN ...... 60
HUMALOG MIX 50-50 ...... 60
HUMALOG MIX 50-50
KWIKPEN........................ 60
HUMALOG MIX 75-25 ...... 60
HUMALOG MIX 75-25
KWIKPEN........................ 60
HUMAPEN LUXURA HD .. 55
HUMATE-P ......................... 33
HUMATROPE ..................... 70
HUMIRA .............................. 73
HUMIRA PEDIATRIC
CROHN'S START ........... 73
HUMIRA PEN CROHN'SUC-HS START ................ 73
HUMULIN 70/30 ................. 60
HUMULIN 70/30 KWIKPEN
.......................................... 60
HUMULIN N ....................... 60
HUMULIN N KWIKPEN .... 60
HUMULIN R ....................... 60
HUMULIN R U-500 (CONC)
KWIKPEN........................ 60
112
HUMULIN R U-500
(CONCENTRATED) ....... 60
HYCAMTIN.........................12
HYCET .................................20
HYCOFENIX ....................... 84
hydralazine ........................... 30
HYDREA ............................. 12
HYDRO 35 ........................... 37
HYDRO 40 ........................... 37
hydrochlorothiazide .............. 30
hydrocodone-acetaminophen 20
hydrocodone-chlorpheniramine
.......................................... 84
hydrocodone-cpmpseudoephed ..................... 84
hydrocodone-homatropine .... 84
hydrocodone-ibuprofen ........ 20
hydrocortisone .......... 43, 47, 66
hydrocortisone acetate .......... 66
hydrocortisone butyrate ........43
hydrocortisone butyr-emollient
.......................................... 43
hydrocortisone valerate ........ 43
hydrocortisone-acetic acid .... 46
hydrocortisone-min oil-wht pet
.......................................... 43
hydrocortisone-pramoxine ... 35,
66
hydromet ............................... 84
hydromorphone..................... 20
HYDROMORPHONE ......... 20
hydromorphone (pf).............. 20
hydroxocobalamin ................ 92
hydroxychloroquine ................ 6
hydroxyprogesterone caproate
.......................................... 75
hydroxyurea .......................... 12
hydroxyzine hcl .................... 83
hydroxyzine pamoate............ 83
HYLENEX ........................... 44
hyolev mb ............................. 88
hyophen ................................ 88
hyoscyamine sulfate ............. 64
hyosyne ................................. 64
HYPERHEP B S/D............... 72
HYPERHEP B S-D
NEONATAL .................... 72
HYPERRAB S/D (PF) ......... 72
HYPER-SAL ........................ 86
HYPERTET S/D (PF) .......... 72
HYPOLANCE AST
LANCING ........................ 55
HYQVIA .............................. 72
HYSINGLA ER ................... 20
HYZAAR ............................. 30
I
ibandronate ........................... 73
IBRANCE ............................ 12
IBUDONE ............................ 20
ibuprofen .............................. 22
ibuprofen-oxycodone ........... 20
ic green ................................. 44
ICAR-C PLUS...................... 92
ICLUSIG .............................. 12
IDAMYCIN PFS .................. 12
idarubicin .............................. 12
IDELVION ........................... 33
iferex 150 forte ..................... 92
IFEX ..................................... 12
ifosfamide ............................. 12
ifosfamide-mesna ................. 12
ILARIS (PF) ......................... 71
ILEVRO ............................... 81
ILOTYCIN ........................... 80
ILUVIEN .............................. 82
imatinib................................. 12
IMBRUVICA ....................... 12
imipenem-cilastatin ................ 6
imipramine hcl...................... 25
imipramine pamoate ............. 25
imiquimod ............................ 71
IMITREX ............................. 17
IMITREX STATDOSE KIT
REFILL ............................ 17
IMITREX STATDOSE PEN17
IMLYGIC ............................. 12
IMPAVIDO ............................ 6
IMURAN.............................. 12
inatal advance ....................... 92
inatal ultra............................. 92
INCONTROL LANCING
DEVICE ........................... 55
INCONTROL PEN NEEDLE
.......................................... 55
INCONTROL SUPER THIN
LANCETS ........................ 55
INCONTROL ULTRA THIN
LANCETS ........................ 55
INCRELEX .......................... 44
INCRUSE ELLIPTA ............ 86
indapamide ........................... 30
INDERAL LA ...................... 30
INDERAL XL ...................... 30
INDIOMIN MB .................... 88
INDOCIN ............................. 22
indocyanine green................. 44
indomethacin ........................ 22
INFANRIX (DTAP) (PF)..... 72
INFASURF........................... 44
infed ...................................... 92
INFINITY STARTER KIT .. 55
INFINITY TEST STRIPS .... 49
INFUMORPH P/F ................ 20
INFUVITE ADULT ............. 92
INFUVITE PEDIATRIC ...... 92
INJECT EASE LANCETS... 55
INJECTAFER ...................... 92
INLYTA ............................... 12
INNOPRAN XL ................... 30
INOVA ................................. 39
INOVA 4-1 ........................... 36
INOVA 8-2 ........................... 36
INSPRA ................................ 30
INSUPEN ............................. 55
INTEGRA F ......................... 92
INTEGRA PLUS .................. 92
INTELENCE .......................... 3
INTERMEZZO .................... 25
INTRON A ........................... 71
introvale ................................ 77
INTUNIV ER ....................... 25
INVACARE LANCETS ...... 55
INVANZ................................. 6
INVEGA ............................... 25
INVEGA SUSTENNA ......... 25
INVEGA TRINZA ............... 25
INVIRASE ............................. 3
INVOKAMET ...................... 63
INVOKANA ........................ 63
IODOPEN ............................ 12
iophen c-nr ............................ 84
IOPIDINE ............................. 83
IPOL ..................................... 72
ipratropium bromide ....... 46, 86
ipratropium-albuterol............ 86
irbesartan .............................. 30
113
irbesartan-hydrochlorothiazide
.......................................... 30
IRENKA ............................... 25
IRESSA ................................ 12
irinotecan .............................. 12
IROSPAN 24/6 ..................... 92
ISENTRESS ........................... 3
ISOCHRON .......................... 35
ISOLYTE S PH 7.4 .............. 90
ISOLYTE-S .......................... 90
isometh-dichloralacetaminophn .................... 17
isomethepten-cafacetaminophen .................. 17
isoniazid .................................. 6
ISOPTO ATROPINE ........... 80
ISOPTO CARPINE ..............81
ISORDIL .............................. 35
ISORDIL TITRADOSE ....... 35
isosorbide dinitrate ............... 35
isosorbide mononitrate ......... 35
isoxsuprine............................ 76
isradipine .............................. 30
ISTALOL ............................. 80
ISTODAX............................. 12
itraconazole............................. 2
ivermectin ............................... 6
IXEMPRA ............................ 12
IXINITY ............................... 33
J
JADENU............................... 44
JAKAFI ................................ 12
JALYN ................................. 87
jantoven ................................ 33
JANUMET ........................... 63
JANUMET XR ..................... 63
JANUVIA ............................. 63
JARDIANCE ........................ 63
jencycla ................................. 75
JENTADUETO .................... 63
JENTADUETO XR .............. 63
JETREA (PF)........................ 81
jevantique lo ......................... 75
JEVTANA ............................ 12
jinteli ..................................... 75
jolessa ................................... 77
jolivette ................................. 75
JUBLIA ................................ 41
juleber ................................... 77
junel 1.5/30 (21) ................... 77
junel 1/20 (21) ...................... 77
junel fe 1.5/30 (28) ............... 77
junel fe 1/20 (28) .................. 77
junel fe 24 ............................. 77
JUXTAPID ........................... 34
K
KADCYLA .......................... 12
KADIAN .............................. 20
kaitlib fe................................ 77
KALBITOR .......................... 86
KALETRA ............................. 3
KALYDECO ........................ 86
KAPVAY ............................. 25
KARBINAL ER ................... 83
kariva (28) ............................ 77
KAYEXALATE ................... 66
KAZANO ............................. 63
KCENTRA ........................... 33
k-effervescent ....................... 89
KEFLEX................................. 4
kelnor 1/35 (28) .................... 77
KENALOG........................... 43
KEPIVANCE ....................... 10
KEPPRA............................... 15
KEPPRA XR ........................ 15
KERAFOAM ....................... 37
KERALAC ........................... 37
KERALYT RX..................... 36
KERALYT SCALP
COMPLETE ..................... 36
KERYDIN ............................ 41
KETEK ................................... 6
ketoconazole ..................... 2, 41
ketoprofen............................. 22
ketorolac ......................... 22, 81
KEVEYIS ............................. 18
KEYTRUDA ........................ 12
KHEDEZLA......................... 25
kimidess (28) ........................ 77
KINERET ............................. 71
KINEVAC ............................ 66
KINNEY BRAND LANCETS
.......................................... 55
KINRIX (PF) ........................ 72
kionex ................................... 66
KITABIS PAK ....................... 6
KLARON ............................. 41
klofensaid ii .......................... 22
KLONOPIN.......................... 15
klor-con ................................ 89
klor-con 10 ........................... 89
klor-con 8 ............................. 89
klor-con m10 ........................ 89
klor-con m15 ........................ 89
klor-con m20 ........................ 89
klor-con sprinkle................... 89
KLOR-CON/25 .................... 89
klor-con/ef ............................ 89
KOATE-DVI ........................ 33
KOGENATE FS ................... 33
KOMBIGLYZE XR ............. 63
KORLYM ............................. 61
KOVALTRY ........................ 33
K-PHOS NO 2 ...................... 88
K-PHOS ORIGINAL ........... 88
k-phos-neutral ....................... 89
KRISTALOSE...................... 66
KRYSTEXXA ...................... 73
k-sol ...................................... 89
k-tab ...................................... 89
K-TAB .................................. 89
kurvelo .................................. 77
KUVAN................................ 61
KYNAMRO ......................... 34
KYPROLIS .......................... 12
L
l norgest/e.estradiol-e.estrad . 77
labetalol ................................ 30
LACRISERT ........................ 81
lactated ringers ..................... 43
lactic acid .............................. 37
lactic acid e ........................... 37
lactulose ................................ 66
LAMICTAL ......................... 15
LAMICTAL ODT ................ 15
LAMICTAL ODT STARTER
(BLUE) ............................. 15
(GREEN) .......................... 15
(ORANGE) ....................... 15
LAMICTAL STARTER
(BLUE) KIT ..................... 15
LAMICTAL STARTER
(GREEN) KIT .................. 15
LAMICTAL STARTER
(ORANGE) KIT ............... 15
114
LAMICTAL XR ................... 15
LAMICTAL XR STARTER
(BLUE) ............................. 15
LAMICTAL XR STARTER
(GREEN) .......................... 15
LAMICTAL XR STARTER
(ORANGE) ....................... 15
LAMISIL ................................ 2
lamivudine .............................. 3
lamivudine-zidovudine ........... 3
lamotrigine ...................... 15, 16
LANCETS ............................ 55
LANCETS,THIN.................. 55
LANCING DEVICE WITH
LANCETS ........................ 55
LANCING SYSTEM ........... 56
LANOXIN ............................ 32
LANOXIN PEDIATRIC ......32
lansoprazole ..........................69
LANTUS .............................. 60
LANTUS SOLOSTAR ......... 60
LANZO LANCING DEVICE
.......................................... 56
larin 1.5/30 (21) .................... 77
larin 1/20 (21) ....................... 77
larin 24 fe .............................. 77
larin fe 1.5/30 (28) ................ 77
larin fe 1/20 (28) ................... 77
LASIX .................................. 30
LASTACAFT ....................... 81
latanoprost ............................ 82
latrix ...................................... 37
LATUDA .............................. 25
laxative peg 3350 .................. 66
layolis fe ............................... 77
LAZANDA ........................... 20
leena 28 ................................. 77
leflunomide ........................... 73
LEMTRADA ........................ 70
LENVIMA ............................ 12
LESCOL ............................... 34
LESCOL XL ......................... 34
lessina ................................... 77
LETAIRIS ............................ 86
letrozole ................................ 12
leucovorin calcium ............... 10
LEUKERAN......................... 12
LEUKINE ............................. 70
leuprolide .............................. 12
levalbuterol hcl ..................... 86
LEVAQUIN ........................... 8
LEVATOL ........................... 30
LEVBID ............................... 64
LEVEMIR ............................ 60
LEVEMIR FLEXTOUCH ... 60
levetiracetam ........................ 16
LEVETIRACETAM IN NACL
(ISO-OS) .......................... 16
levobunolol ........................... 80
levocarnitine ......................... 44
levocarnitine (with sugar)..... 44
levocetirizine ........................ 83
levofloxacin ...................... 8, 80
levofloxacin in d5w ................ 8
levomefolate dha .................. 92
levonest (28) ......................... 77
levonorgestrel-ethinyl estrad 77
levonorg-eth estrad triphasic 78
levora-28............................... 78
levorphanol tartrate .............. 20
levothyroxine........................ 64
levoxyl .................................. 64
LEVSIN ................................ 64
LEVSIN/SL .......................... 64
LEVULAN ........................... 37
LEXAPRO ........................... 25
LEXIVA ................................. 3
LIALDA ............................... 66
LIBERTY TEST .................. 49
LIBRAX (WITH
CLIDINIUM) ................... 64
lidocaine ............................... 40
lidocaine (pf) ........................ 40
lidocaine hcl ......................... 40
lidocaine hcl-hydrocortison ac
.................................... 40, 66
LIDOCAINE HCLHYDROCORTISON AC . 66
lidocaine viscous .................. 40
lidocaine-epinephrine ........... 40
lidocaine-hydrocortisone-aloe
.......................................... 66
lidocaine-prilocaine .............. 40
LIDOCAINE-TETRACAINE
.......................................... 40
LIDODERM ......................... 40
lido-k .................................... 40
lidopin................................... 40
LIDOPIN .............................. 40
LIDORX ............................... 40
LIDOVEX ............................ 40
LIFESHIELD BLUNT
CANNULA ...................... 56
LILETTA.............................. 74
lindane .................................. 43
linezolid .................................. 6
linezolid-0.9% sodium chloride
............................................ 6
LINZESS .............................. 66
liothyronine .......................... 64
LIPITOR ............................... 34
LIPOCHOL PLUS ............... 44
lipodox .................................. 12
LIPOFEN.............................. 34
lisinopril................................ 30
lisinopril-hydrochlorothiazide
.......................................... 30
LITE TOUCH LANCETS.... 56
lithium carbonate .................. 25
lithium citrate ....................... 25
LITHOBID ........................... 25
LITHOSTAT ........................ 44
LIVALO ............................... 34
LIVIXIL PAK ...................... 40
LO LOESTRIN FE ............... 78
LOCAL ANESTHESIA
NEEDLE 22GX2 .............. 56
LOCOID ............................... 43
LOCOID LIPOCREAM ....... 43
LODOSYN ........................... 17
LOESTRIN 1.5/30 (21) ........ 78
LOESTRIN 1/20 (21) ........... 78
LOESTRIN FE 1.5/30 (28DAY) ................................ 78
LOESTRIN FE 1/20 (28-DAY)
.......................................... 78
LOFIBRA ............................. 34
lomedia 24 fe ........................ 78
LOMOTIL ............................ 65
LONSURF ............................ 12
loperamide ............................ 65
LOPID .................................. 34
lopreeza ................................ 75
LOPRESSOR ....................... 30
LOPRESSOR HCT .............. 30
LOPROX .............................. 41
lorazepam ............................. 25
115
lorazepam intensol ................ 25
lorcet (hydrocodone) ............ 21
lorcet hd ................................ 21
lorcet plus ............................. 21
lortab 10-325 ........................ 21
lortab 5-325 ..........................21
lortab 7.5-325 ....................... 21
LORTAB ELIXIR ................ 21
lortuss ex ............................... 84
loryna (28) ............................ 78
LORZONE ........................... 18
losartan ................................. 30
losartan-hydrochlorothiazide 30
LOSEASONIQUE ................ 78
LOTEMAX........................... 82
LOTENSIN........................... 30
LOTENSIN HCT.................. 30
LOTREL ............................... 30
LOTRISONE ........................ 41
LOTRONEX......................... 66
LOUTREX ........................... 37
lovastatin............................... 34
LOVENOX ........................... 33
low-ogestrel (28) .................. 78
loxapine succinate ................ 25
LP LITE PAK ....................... 40
lta pre-attached ..................... 40
LUCENTIS ........................... 81
ludent fluoride ................ 92, 93
lugols .................................... 89
LUMIGAN ........................... 82
LUMIZYME......................... 61
LUNESTA ............................ 25
LUPANETA PACK (1
MONTH) .......................... 76
LUPANETA PACK (3
MONTH) .......................... 76
LUPRON DEPOT ................ 12
LUPRON DEPOT (3
MONTH) .......................... 12
LUPRON DEPOT (4
MONTH) .......................... 12
LUPRON DEPOT (6
MONTH) .......................... 12
LUPRON DEPOT-PED ....... 12
LUPRON DEPOT-PED (3
MONTH) .......................... 12
lutera (28) ............................. 78
luxamend .............................. 37
LUXIQ ................................. 43
LUZU ................................... 41
LYCELLE ............................ 43
LYNPARZA......................... 12
LYRICA ............................... 16
LYSODREN......................... 12
LYSTEDA............................ 76
lyza ....................................... 75
M
M.V.I. PEDIATRIC ............. 93
M.V.I.-12 (WITHOUT
VITAMIN K) ................... 93
mac ....................................... 37
macnatal cn dha .................... 93
MACROBID .......................... 9
MACRODANTIN .................. 9
MACUGEN.......................... 81
MAGNEBIND 400 .............. 66
MAKENA ............................ 75
MALARONE ......................... 6
MALARONE PEDIATRIC ... 6
malathion .............................. 43
maprotiline ........................... 25
MAR-COF BP ...................... 84
MAR-COF CG ..................... 84
margesic ............................... 21
MARINOL ........................... 66
marlissa................................. 78
MARNATAL-F.................... 93
MARPLAN .......................... 25
MARQIBO ........................... 12
marten-tab............................. 21
MATULANE ....................... 12
MAVIK ................................ 30
MAXALT ............................. 17
MAXALT-MLT ................... 17
MAXARON FORTE............ 93
MAXFE (FOLATEDOCUSATE) ................... 93
MAXIDEX ........................... 82
MAXINATE......................... 93
MAXIPIME............................ 5
MAXITROL ......................... 82
MAXZIDE ........................... 30
MAXZIDE-25MG................ 30
mb hydrogel.......................... 37
mb hydrogel (cyclomethicone)
.......................................... 37
m-clear wc ............................ 84
meclizine .............................. 66
meclofenamate...................... 22
MEDISENSE THIN
LANCETS ........................ 56
MEDLANCE PLUS
LANCETS ........................ 56
MEDROL ............................. 47
MEDROL (PAK) ................. 47
medroxyprogesterone ........... 75
mefenamic acid..................... 22
mefloquine .............................. 6
MEFOXIN IN DEXTROSE
(ISO-OSM) ......................... 5
MEGACE ............................. 12
MEGACE ES ....................... 12
megestrol .............................. 12
MEKINIST ........................... 12
meloxicam ............................ 22
melphalan hcl ....................... 13
memantine ............................ 18
MEMANTINE...................... 18
MENACTRA (PF) ............... 72
M-END MAX D ................... 84
M-END PE ........................... 84
MENEST .............................. 75
MENHIBRIX (PF) ............... 72
MENOMUNE - A/C/Y/W-135
.......................................... 72
MENOMUNE - A/C/Y/W-135
(PF) ................................... 72
MENOPUR .......................... 61
MENOSTAR ........................ 75
MENTAX ............................. 41
MENVEO A-C-Y-W-135-DIP
(PF) ................................... 72
meperidine ............................ 21
meperidine (pf) ..................... 21
MEPHYTON ........................ 33
meprobamate ........................ 18
MEPRON ............................... 6
mercaptopurine ..................... 13
meropenem ............................. 6
MERREM............................... 7
mesalamine ........................... 66
mesalamine with cleansing
wipe .................................. 67
mesna .................................... 10
MESNEX.............................. 10
MESTINON ......................... 19
116
MESTINON TIMESPAN ....19
METADATE CD.................. 25
metadate er............................ 25
metaproterenol ...................... 86
metaxall ................................ 19
metaxalone ............................ 19
metformin ............................. 63
methadone............................. 21
methadose ............................. 21
methamphetamine................. 25
methazolamide ...................... 82
methenamine hippurate .......... 9
methenamine mandelate ......... 9
methen-sod phos-meth bluehyos................................... 88
methergine ............................ 79
methimazole ......................... 47
METHITEST ........................ 62
methocarbamol ..................... 19
methotrexate sodium ............ 13
methotrexate sodium (pf) ..... 13
methoxsalen rapid ................. 37
methscopolamine .................. 65
methyclothiazide................... 30
methyl salicylate ................... 37
methyldopa ........................... 30
methyldopahydrochlorothiazide .......... 30
methyldopate ........................ 30
methylergonovine ................. 79
METHYLIN ......................... 25
methylphenidate ................... 25
methylprednisolone .............. 47
methyltestosterone ................ 62
metipranolol .......................... 80
metoclopramide hcl .............. 67
metolazone ............................ 30
METOPIRONE .................... 44
metoprolol succinate ............. 30
metoprolol ta-hydrochlorothiaz
.......................................... 30
metoprolol tartrate ................ 30
METOZOLV ODT ............... 67
metro i.v. ................................. 7
METROCREAM .................. 39
METROGEL ........................ 39
METROGEL VAGINAL ..... 76
METROLOTION ................. 39
metronidazole ............. 7, 39, 76
metronidazole in nacl (iso-os) 7
mexiletine ............................. 27
MIACALCIN ....................... 62
MICARDIS .......................... 30
MICARDIS HCT ................. 30
miconazole-3 ........................ 76
MICRO BLOOD GLUCOSE
.......................................... 49
MICRO THIN LANCETS ... 56
MICRODOT BLOOD
GLUCOSE SYSTEM. 49, 56
microgestin 1.5/30 (21) ........ 78
microgestin 1/20 (21) ........... 78
MICROGESTIN 24 FE ........ 78
microgestin fe 1.5/30 (28) .... 78
microgestin fe 1/20 (28) ....... 78
MICROLET LANCET......... 56
MICROZIDE........................ 30
midodrine ............................. 44
migergot ............................... 17
miglitol ................................. 63
MIGRANAL ........................ 17
milk of magnesia concentrated
.......................................... 67
millipred ............................... 47
MILLIPRED......................... 47
millipred dp .......................... 47
mimvey ................................. 75
mimvey lo............................. 75
MINASTRIN 24 FE ............. 78
MINI LANCING DEVICE .. 56
MINI ULTRA-THIN II ........ 56
MINIPRESS ......................... 30
MINITRAN .......................... 35
MINIVELLE ........................ 75
MINOCIN .............................. 9
minocycline ............................ 9
minoxidil .............................. 30
MIOCHOL-E ....................... 81
miostat .................................. 82
MIRAPEX ............................ 17
MIRAPEX ER ...................... 17
MIRCERA............................ 70
MIRCETTE (28) .................. 78
MIRENA .............................. 74
mirtazapine ........................... 25
MIRVASO ........................... 39
misoprostol ........................... 69
MITIGARE .......................... 73
mitomycin ............................. 13
MITOSOL ............................ 82
mitoxantrone......................... 13
M-M-R II (PF) ...................... 72
MOBIC ................................. 22
modafinil .............................. 25
moderiba ............................... 70
moderiba dose pack .............. 70
MODICON (28) ................... 78
moexipril .............................. 30
moexipril-hydrochlorothiazide
.......................................... 30
molindone ............................. 25
mometasone .................... 43, 86
mondoxyne nl ......................... 9
MONOCLATE-P ................. 33
MONODOX ........................... 9
monoject 0.9% sodium
chloride ............................. 44
MONOJECT BLOOD
COLLECTION ................. 56
MONOJECT HYPODERMIC
NEEDLES ........................ 56
MONOJECT MEDICATION
TRANSF NDL ................. 56
monoject prefill (pf) ............. 33
monoject prefill advanced (pf)
.......................................... 33
monoject prefill advanced ns 44
monoject prefill saline flush . 44
MONOLET THIN LANCETS
.......................................... 56
mono-linyah.......................... 78
mononessa (28)..................... 78
MONONINE ........................ 33
montelukast .......................... 86
MONUROL ............................ 9
morgidox ................................ 9
MORGIDOX 2X100 .............. 9
morphine............................... 21
MORPHINE ......................... 21
morphine (pf) ........................ 21
morphine concentrate ........... 21
MOTOFEN ........................... 65
MOVANTIK ........................ 67
MOVIPREP .......................... 67
MOXATAG............................ 8
MOXEZA ............................. 80
moxifloxacin........................... 8
117
MOXIFLOXACINSOD.ACE,SUL-WATER ... 8
MOZOBIL ............................ 70
MS CONTIN ........................ 21
MUGARD ............................ 46
MULTAQ ............................. 27
multi-delyn with iron ............ 93
MULTI-DRAW NEEDLE ... 56
multigen folic........................93
multigen plus ........................ 93
MULTI-LANCET DEVICE 2
.......................................... 56
multi-vit with fluoride-iron...93
multi-vitamin with fluoride ..93
multivitamins with fluoride ..93
mupirocin ..............................41
mupirocin calcium ................ 41
MUSTARGEN ..................... 13
mvc-fluoride ......................... 93
M-VIT................................... 93
my way ................................. 78
MYALEPT ........................... 62
MYAMBUTOL ...................... 7
MYCAMINE .......................... 2
MYCOBUTIN ........................ 7
mycophenolate mofetil ......... 13
mycophenolate sodium ......... 13
MYDRIACYL ...................... 81
myferon 150 forte ................. 93
MYFORTIC ......................... 13
MYGLUCOHEALTH .... 49, 56
MYGLUCOHEALTH
LANCETS ........................ 56
MYLERAN .......................... 13
mynatal ................................. 93
mynatal advance ................... 93
mynatal plus.......................... 93
mynatal-z .............................. 93
mynate 90 plus ...................... 93
mynephrocaps ....................... 93
MYOBLOC .......................... 72
myorisan ............................... 39
MYOZYME ......................... 62
MYRBETRIQ....................... 87
MYSOLINE ......................... 16
myzilra .................................. 78
N
NABI-HB ............................. 72
nabumetone........................... 22
nadolol .................................. 30
nadolol-bendroflumethiazide 30
nafcillin................................... 8
nafcillin in dextrose iso-osm .. 8
naftifine ................................ 41
NAFTIFINE ......................... 41
NAFTIN ............................... 41
NAGLAZYME..................... 62
nalbuphine ............................ 22
naloxone ............................... 22
naltrexone ............................. 22
NAMENDA ......................... 18
NAMENDA TITRATION
PAK .................................. 18
NAMENDA XR ................... 18
NAMZARIC......................... 18
NAPRELAN CR .................. 22
NAPROSYN ........................ 22
naproxen ............................... 22
naproxen sodium .................. 22
naratriptan............................. 17
NARCAN ............................. 22
NARDIL ............................... 25
NASACORT ........................ 86
nasal allergy.......................... 86
NASONEX ........................... 86
NATACHEW (FE BISGLYCINATE) .................. 93
NATACYN .......................... 80
NATAZIA ............................ 78
nateglinide ............................ 63
NATELLE ONE ................... 93
NATESTO............................ 62
NATPARA ........................... 62
NATRECOR ........................ 35
NATROBA........................... 43
natural b-100 complex .......... 93
nature-throid ......................... 64
NAVELBINE ....................... 13
NEBUPENT ........................... 7
NEBUSAL ........................... 86
necon 0.5/35 (28).................. 78
necon 1/35 (28)..................... 78
necon 1/50 (28)..................... 78
necon 10/11 (28)................... 78
necon 7/7/7 (28) ................... 78
NEEDLES, HUBER
DISPOSABLE.................. 56
NEEVODHA (WITH ALGAL
OIL) .................................. 93
nefazodone............................ 25
neomycin ................................ 7
neomycin-bacitracin-poly-hc 82
neomycin-bacitracinpolymyxin......................... 80
neomycin-polymyxin b gu.... 43
neomycin-polymyxin bdexameth .......................... 82
neomycin-polymyxingramicidin ......................... 80
neomycin-polymyxin-hc 46, 82
neo-polycin ........................... 80
neo-polycin hc ...................... 82
NEORAL .............................. 13
NEOSALUS ......................... 37
NEOSPORIN (NEO-POLYMGRAMICID) .................... 80
NEOSPORIN GU IRRIGANT
.......................................... 44
NEO-SYNALAR.................. 41
NEO-SYNALAR KIT .......... 41
nephplex rx ........................... 93
NEPHROCAPS .................... 93
NEPHROCAPS QT.............. 93
NEPHRON FA ..................... 93
NEPHRO-VITE.................... 93
nephro-vite rx ....................... 93
NEPTAZANE ...................... 82
NESINA ............................... 63
NESTABS ............................ 93
NESTABS ABC ................... 93
NESTABS DHA................... 93
neuac ..................................... 39
NEULASTA ......................... 70
NEUPOGEN ........................ 70
NEUPRO .............................. 17
NEURIN-SL ......................... 93
NEURONTIN ....................... 16
NEUTEK 2TEK TEST
STRIPS ............................. 49
NEVANAC .......................... 81
nevirapine ............................... 3
newgen.................................. 93
NEXA PLUS ........................ 93
NEXAVAR .......................... 13
NEXAVIR ............................ 94
NEXIUM 24HR ................... 69
118
NEXIUM PACKET..............69
NEXPLANON ......................76
next choice one dose ............. 78
niacin .................................... 34
NIACOR ............................... 34
NIASPAN EXTENDEDRELEASE......................... 34
nicardipine ............................ 30
NICODERM CQ .................. 45
NICOMIDE .......................... 94
NICOMIDE (SELENIUMCHROMIUM) .................. 94
NICORETTE ........................ 45
nicotine ................................. 45
NICOTINE (POLACRILEX)
.......................................... 45
NICOTROL .......................... 45
NICOTROL NS .................... 45
nifedical xl ............................ 30
nifedipine .............................. 30
nikki (28) .............................. 78
NILANDRON ...................... 13
nimodipine ............................ 30
NINJACOF-XG .................... 84
NINLARO ............................ 13
NIPENT ................................ 13
nisoldipine ............................ 30
nitro-bid ................................ 35
NITRO-DUR ........................ 35
nitrofurantoin .......................... 9
nitrofurantoin macrocrystal .. 10
nitrofurantoin monohyd/mcryst .................................. 10
nitroglycerin ......................... 35
nitroglycerin in 5 % dextrose35
NITROLINGUAL ................ 35
NITROMIST ........................ 35
NITROSTAT ........................ 35
nitro-time .............................. 35
NIVA-FOL ........................... 94
NIVA-PLUS ......................... 94
nizatidine .............................. 69
NIZORAL............................. 41
nodolor .................................. 18
NOKOR NEEDLE ............... 56
nora-be .................................. 75
NORCO ................................ 21
NORDITROPIN FLEXPRO 70
noreth-ethinyl estradiol-iron . 78
norethindrone (contraceptive)
.......................................... 75
norethindrone acetate ........... 75
norethindrone ac-eth estradiol
.................................... 75, 78
norethindrone-e.estradiol-iron
.......................................... 78
norgestimate-ethinyl estradiol
.......................................... 78
NORINYL 1+35 (28) ........... 78
NORITATE .......................... 39
norlyroc ................................ 75
normal saline flush ............... 44
NORMOSOL-R ................... 89
NORMOSOL-R PH 7.4 ....... 90
NORPACE ........................... 27
NORPACE CR ..................... 27
NORPRAMIN ...................... 25
NOR-QD .............................. 75
NORTHERA ........................ 44
nortrel 0.5/35 (28) ................ 78
nortrel 1/35 (21) ................... 78
nortrel 7/7/7 (28) .................. 78
nortriptyline .......................... 25
NORVASC ........................... 31
NORVIR................................. 3
NOVA MAX BLOOD
NOVA MAX GLUCOSE
TEST ................................ 49
NOVA SAFETY LANCETS56
NOVA SUREFLEX
LANCETS ........................ 56
NOVACORT........................ 67
NOVACORT (WITH ALOE)
.......................................... 40
novarel .................................. 62
NOVOEIGHT ...................... 33
NOVOFINE 32 .................... 56
NOVOFINE AUTOCOVER 56
NOVOFINE PLUS ............... 56
NOVOLIN 70/30.................. 61
NOVOLIN N ........................ 61
NOVOLIN R ........................ 61
NOVOLOG .......................... 61
NOVOLOG FLEXPEN........ 61
NOVOLOG MIX 70-30 ....... 61
NOVOLOG MIX 70-30
FLEXPEN ........................ 61
NOVOLOG PENFILL ......... 61
NOVOPEN ECHO ............... 56
NOVOSEVEN RT ............... 33
NOVOTWIST ...................... 56
NOXAFIL .............................. 2
np thyroid ............................. 64
NPLATE ............................... 33
NUCALA ............................. 86
NUCYNTA .......................... 22
NUCYNTA ER .................... 23
NUEDEXTA ........................ 18
NUFERA .............................. 94
NULEV ................................ 65
NULOJIX ............................. 13
NULYTELY WITH FLAVOR
PACKS ............................. 67
NUOX .................................. 39
NUPLAZID .......................... 25
NUTRICAP .......................... 94
NUTROPIN AQ ................... 70
NUTROPIN AQ NUSPIN.... 70
NUVARING ......................... 76
NUVESSA............................ 76
NUVIGIL ............................. 25
nyamyc ................................. 41
NYATA ................................ 41
NYMALIZE ......................... 31
nystatin ............................. 2, 41
nystatin-triamcinolone .......... 41
nystop ................................... 41
O
OB COMPLETE .................. 94
OB COMPLETE GOLD ...... 94
OB COMPLETE ONE ......... 94
OB COMPLETE PETITE .... 94
OB COMPLETE PREMIER 94
OB COMPLETE WITH DHA
.......................................... 94
OBIZUR ............................... 33
OBREDON ........................... 84
obstetrix dha ......................... 94
OBSTETRIX EC .................. 94
OBTREX DHA .................... 94
O-CAL FA ............................ 94
O-CAL PRENATAL ............ 94
OCALIVA ............................ 67
ocella .................................... 78
OCTAGAM .......................... 72
octreotide acetate .................. 13
119
OCUFEN .............................. 81
OCUFLOX ........................... 80
ODEFSEY .............................. 3
ODOMZO............................. 13
OFEV .................................... 86
ofloxacin ..................... 8, 46, 80
ogestrel (28) ..........................78
olanzapine .............................26
olanzapine-fluoxetine ........... 26
OLEPTRO ER ......................26
olopatadine ..................... 46, 81
OLUX ................................... 43
OLUX-E ............................... 43
OLYSIO ................................. 3
OMECLAMOX-PAK........... 69
omega-3 acid ethyl esters ..... 34
omeprazole ........................... 69
omeprazole magnesium ........ 69
omeprazole-sodium
bicarbonate ....................... 69
OMIDRIA............................. 81
OMNARIS ............................ 86
OMNIPRED ......................... 82
OMNITROPE ....................... 70
ON CALL EXPRESS METER
.......................................... 56
ON CALL EXPRESS TEST
STRIP ............................... 49
ON CALL LANCET ............ 56
ON CALL LANCING
DEVICE ........................... 56
ON CALL PLUS LANCET . 56
ON CALL PLUS LANCING
DEVICE ........................... 56
ON CALL PLUS METER....56
ON CALL PLUS TEST STRIP
..........................................49
ON CALL VIVID METER ..56
ON CALL VIVID PAL
METER.............................56
ON CALL VIVID TEST
STRIP ...............................49
ondansetron...........................67
ondansetron hcl .....................67
ondansetron hcl (pf) .............. 67
ONE A DAY WOMEN'S
PRENATAL DHA............ 94
one daily prenatal ................. 94
ONE DAILY PRENATAL... 94
ONETOUCH DELICA LANC
DEVICE ........................... 57
ONETOUCH SURESOFT
LANCING DEV............... 57
ONETOUCH ULTRA TEST
.......................................... 49
ONETOUCH ULTRA2........ 57
ONETOUCH ULTRAMINI 57
ONETOUCH ULTRASOFT
LANCETS ........................ 57
ONETOUCH VERIO ........... 49
ONETOUCH VERIO FLEX 57
ONETOUCH VERIO IQ
METER ............................ 57
ONETOUCH VERIO SYNC
.......................................... 57
ONETOUCH VERIO
SYSTEM .......................... 57
ONEXTON........................... 39
ONFI..................................... 16
ONGLYZA........................... 63
ONMEL.................................. 2
ON-THE-GO LANCETS ..... 57
OPANA ................................ 21
OPANA ER .......................... 21
opcicon one-step ................... 78
OPDIVO ............................... 13
opium tincture ...................... 65
OPSUMIT ............................ 86
OPTIUM EZ......................... 49
OPTIUM TEST .................... 49
OPTUMRX .................... 49, 57
ORACEA ............................... 9
ORACIT ............................... 88
ORAFATE ........................... 46
ORALAIR ............................ 72
oralone .................................. 46
ORAMAGICRX................... 46
ORAP ................................... 26
ORAPRED ODT .................. 47
ORAVIG ................................ 2
ORBACTIV ........................... 7
ORENCIA ............................ 74
ORENCIA (WITH
MALTOSE)...................... 74
ORENCIA CLICKJECT ...... 74
ORENITRAM ...................... 31
ORFADIN ............................ 44
ORKAMBI ........................... 86
orphenadrine citrate .............. 19
orsythia ................................. 78
ortho d................................... 94
ORTHO MICRONOR .......... 75
ORTHO TRI-CYCLEN (28) 78
ORTHO TRI-CYCLEN LO
(28) ................................... 78
ORTHO-CYCLEN (28) ....... 78
ORTHO-NOVUM 1/35 (28) 79
ORTHO-NOVUM 7/7/7 (28)
.......................................... 79
oscimin ................................. 65
oscimin sl.............................. 65
oscimin sr ............................. 65
OSENI .................................. 63
OSMOPREP ......................... 67
OSPHENA............................ 76
OTEZLA .............................. 74
OTEZLA STARTER ............ 74
OTREXUP (PF) ................... 74
OVACE ................................ 35
OVACE PLUS ..................... 36
OVACE PLUS SHAMPOO . 35
OVACE PLUS WASH......... 36
OVCON-35 (28) ................... 79
OVIDE.................................. 43
OVIDREL ............................ 62
oxacillin .................................. 8
oxacillin in dextrose(iso-osm) 8
oxaliplatin ............................. 13
OXANDRIN ......................... 62
oxandrolone .......................... 62
oxaprozin .............................. 23
OXAYDO ............................. 21
oxazepam .............................. 26
oxcarbazepine ....................... 16
oxiconazole........................... 41
OXISTAT ............................. 41
OXSORALEN ...................... 37
OXSORALEN ULTRA ....... 37
OXTELLAR XR .................. 16
oxybutynin chloride .............. 87
oxycodone ............................ 21
OXYCODONE ..................... 21
oxycodone-acetaminophen ... 21
oxycodone-aspirin ................ 21
OXYCONTIN ...................... 21
oxymorphone ........................ 21
OXYTROL ........................... 87
120
P
pacerone ................................ 27
paclitaxel............................... 13
PACNEX .............................. 39
PAIRE OB PLUS DHA........ 94
paliperidone .......................... 26
PAMELOR ........................... 26
pamidronate .......................... 62
PANCREAZE....................... 67
PANDEL ..............................43
PANRETIN .......................... 37
pantoprazole ......................... 69
papaverine............................. 31
PARAFON FORTE DSC .....19
PARAGARD T 380A ........... 74
PARASYMPATH NERVE
NDL 20 G X6 ................... 57
paregoric ............................... 65
PAREMYD........................... 81
paricalcitol ............................ 62
PARICALCITOL ................. 62
PARLODEL ......................... 17
PARNATE ............................ 26
paromomycin .......................... 7
paroxetine hcl ....................... 26
PASER .................................... 7
PATADAY ........................... 81
PATANASE ......................... 46
PATANOL ........................... 81
PAXIL .................................. 26
PAXIL CR ............................ 26
PAZEO ................................. 81
PCE ......................................... 5
PED MULTIVITAMINSA,B,D,E,K,ZN .................. 94
PEDIAPRED ........................ 47
PEDIARIX (PF) ................... 72
PEDVAX HIB (PF) .............. 72
peg 3350-electrolytes............67
peg-3350 with flavor packs ..67
PEGANONE.........................16
PEGASYS ............................70
PEGASYS PROCLICK........ 70
peg-electrolyte soln .............. 67
PEGINTRON .......................70
PEGINTRON REDIPEN...... 70
peg-prep ................................67
PEN NEEDLE ......................57
PEN NEEDLE, DIABETIC .57
PENICILLIN G POT IN
DEXTROSE ....................... 8
penicillin g potassium............. 8
penicillin g procaine ............... 8
penicillin g sodium ................. 8
penicillin v potassium............. 8
PENLAC .............................. 41
PENNSAID .......................... 23
PENTACEL (PF) ................. 72
PENTAM ............................... 7
PENTASA ............................ 67
pentazocine-naloxone ........... 23
PENTIPS .............................. 57
PENTIPS PEN NEEDLE ..... 57
pentoxifylline ....................... 33
PEPCID ................................ 69
PERCOCET ......................... 21
PERFOROMIST .................. 86
PERIDEX ............................. 46
perindopril erbumine ............ 31
periogard............................... 46
PERJETA ............................. 13
permethrin ............................ 43
perphenazine......................... 26
perphenazine-amitriptyline... 26
perry prenatal........................ 94
PERTZYE ............................ 67
PEXEVA .............................. 26
pfizerpen-g ............................. 8
PHARMACIST CHOICE .... 49
PHARMACIST CHOICE
GLUCOSE SYS ............... 57
PHASEAL PROTECTOR ... 57
phenadoz............................... 83
phenazopyridine ................... 88
phenelzine............................. 26
phenergan ............................. 83
PHENERGAN...................... 83
phenobarbital ........................ 16
phenohytro............................ 65
phenoxybenzamine ............... 31
phentolamine ........................ 31
phenylephrine hcl ................. 83
phenylhistine dh ................... 84
PHENYTEK ......................... 16
phenytoin .............................. 16
phenytoin sodium ................. 16
phenytoin sodium extended.. 16
philith ................................... 79
PHOSLO .............................. 67
PHOSLYRA ......................... 67
phospha 250 neutral.............. 89
phosphasal ............................ 88
phosphate laxative ................ 67
PHOSPHOLINE IODIDE .... 80
PHOTOFRIN........................ 13
PHYSIOLYTE ..................... 44
PHYSIOSOL IRRIGATION 44
PHYTONADIONE
(VITAMIN K1) ................ 33
PICATO................................ 37
pilocarpine hcl .......... 44, 46, 81
pimozide ............................... 26
pimtrea (28) .......................... 79
pindolol................................. 31
pioglitazone .......................... 63
pioglitazone-glimepiride ...... 63
pioglitazone-metformin ........ 63
piperacillin-tazobactam .......... 8
pirmella................................. 79
piroxicam .............................. 23
PLAN B ONE-STEP ............ 79
PLAQUENIL.......................... 7
PLASMA-LYTE 148 ........... 90
PLASMA-LYTE A .............. 90
PLAVIX ............................... 33
PLEGRIDY .......................... 70
PLEXION ............................. 39
PLEXION CLEANSING
CLOTHS .......................... 39
PLIAGLIS ............................ 40
PNEUMOVAX 23 ............... 72
pnv 29-1 ................................ 94
pnv ob+dha ........................... 94
pnv-dha ................................. 94
pnv-dha + docusate............... 94
pnv-ferrous fumarate-docu-fa
.......................................... 94
pnv-omega ............................ 94
pnv-select.............................. 94
pnv-vp-u ............................... 94
PODOCON........................... 36
podofilox .............................. 37
POLY HUB NEEDLE.......... 57
polycin .................................. 80
polyethylene glycol 3350 ..... 67
poly-iron 150 forte................ 94
polymyxin b sulfate ................ 7
121
polymyxin b sulf-trimethoprim
.......................................... 80
POLYTRIM .......................... 80
POLY-TUSSIN AC .............. 84
POLY-VI-FLOR................... 94
POLY-VI-FLOR FS ............. 94
POLY-VI-FLOR WITH IRON
.......................................... 94
poly-vitamin with iron .......... 94
POMALYST......................... 70
PONSTEL............................. 23
portia ..................................... 79
pot,sodium citrate-citric acid 88
POTABA .............................. 89
potassium acetate .................. 89
potassium bicarb and chloride
.......................................... 89
potassium bicarb-citric acid ..89
potassium chlorid-d50.45%nacl ......................... 89
potassium chloride ................ 89
potassium chloride in 0.9%nacl
.......................................... 89
potassium chloride in 5 % dex
.......................................... 89
potassium chloride in lr-d5 ... 89
potassium chloride-0.45 % nacl
.......................................... 89
potassium chloride-d50.2%nacl ........................... 89
potassium citrate ................... 88
potassium citrate-citric acid ..88
POTASSIUM HYDROXIDE
..........................................36
potassium phosphate m-/dbasic ..................................89
POTIGA ...............................16
PR BENZOYL PEROXIDE .39
pr natal 400 ........................... 94
pr natal 400 ec ...................... 94
pr natal 430 ........................... 94
pr natal 430 ec ...................... 94
PRADAXA ........................... 33
PRALUENT PEN ................. 34
PRALUENT SYRINGE ....... 34
pramcort ............................... 67
pramipexole .......................... 17
PRAMOSONE ..................... 36
PRAMOSONE E .................. 36
PRANDIN ............................ 63
PRAVACHOL ..................... 34
pravastatin ............................ 34
prazosin ................................ 31
PRECISION PCX PLUS TEST
.......................................... 49
PRECISION PCX TEST ...... 50
PRECISION POINT OF
CARE TEST..................... 50
PRECISION Q-I-D TEST .... 50
PRECISION XTRA
MONITOR ....................... 57
PRECISION XTRA TEST ... 50
PRECOSE ............................ 63
PRED FORTE ...................... 82
PRED MILD ........................ 82
PRED-G ............................... 82
PRED-G S.O.P. .................... 82
prednicarbate ........................ 43
prednisolone ......................... 47
prednisolone acetate ............. 82
prednisolone sodium phosphate
.................................... 47, 82
prednisone ............................ 47
prednisone intensol ............... 47
PREFERA-OB ..................... 94
PREFERA-OB ONE ............ 94
PREFERA-OB PLUS DHA . 94
PREFEST ............................. 75
PREGNYL ........................... 62
PREMARIN ......................... 75
PREMIUM BLOOD
PREMIUM V10 ............. 50, 57
PREMPHASE ...................... 75
PREMPRO ........................... 75
prena1 chew.......................... 94
prena1 pearl .......................... 94
prenaissance ......................... 94
prenaissance next.................. 95
prenaissance plus .................. 95
PRENATA ........................... 95
prenatabs fa .......................... 95
prenatabs rx .......................... 95
prenatal ................................. 95
PRENATAL + DHA ............ 95
prenatal complete ................. 95
prenatal formula ................... 95
prenatal multi-dha (algal oil) 95
prenatal one daily ................. 95
prenatal plus ......................... 95
prenatal plus (calcium carb) . 95
prenatal vit#96-ferrous fum-fa
.......................................... 95
prenatal vitamin .................... 95
prenatal vitamin plus low iron
.......................................... 95
prenatal-u .............................. 95
PRENATE AM..................... 95
PRENATE CHEWABLE ..... 95
PRENATE DHA (FERR ASP
GLYCIN).......................... 95
PRENATE ELITE (IRON ASP
GLYC) .............................. 95
PRENATE ENHANCE ........ 95
PRENATE
ESSENTIAL(IRON-ASPGL) ................................... 95
PRENATE MINI .................. 95
PRENATE MINI (FERR ASP
GLYCIN).......................... 95
PRENATE PIXIE ................. 95
PRENATE RESTORE ......... 95
PRENATE STAR ................. 95
PREPIDIL ............................ 76
preplus .................................. 95
PREPOPIK ........................... 67
PREQUE 10 ......................... 95
PRESERA ............................ 37
PRESSURE ACTIVATED
LANCETS ........................ 57
PRESTALIA ........................ 31
PRESTO PRO BLOOD
pretab .................................... 95
PREVACID 24HR ............... 69
PREVACID SOLUTAB....... 69
prevalite ................................ 34
PREVIDENT ........................ 46
PREVIDENT 5000 BOOSTER
PLUS ................................ 46
PREVIDENT 5000 DRY
MOUTH ........................... 46
122
PREVIDENT 5000 ENAMEL
PROTECT ........................ 46
PREVIDENT 5000
SENSITIVE ...................... 46
previfem ................................ 79
PREVNAR 13 (PF) .............. 72
PREVPAC ............................ 69
PREZCOBIX .......................... 3
PREZISTA ............................. 3
PRIFTIN ................................. 7
PRILOSEC ........................... 69
PRILOSEC OTC .................. 69
PRIMAQUINE ....................... 7
PRIMAXIN IV ....................... 7
primidone .............................. 16
PRIMLEV.............................21
PRIMSOL ............................. 10
PRINIVIL ............................. 31
PRISTIQ ............................... 26
PRIVIGEN ........................... 72
PROAIR HFA ...................... 86
PROAIR RESPICLICK........86
probenecid ............................ 73
procainamide ........................ 27
PROCARDIA ....................... 31
PROCARDIA XL ................. 31
procentra ............................... 26
prochlorperazine ................... 67
prochlorperazine edisylate .... 67
prochlorperazine maleate......67
PROCORT............................67
PROCRIT .............................70
PROCTOCORT....................67
PROCTOFOAM HC ............67
procto-med hc .......................67
procto-pak ............................. 67
proctosol hc .......................... 67
proctozone-hc ....................... 67
PROCYSBI........................... 88
PRODIGY AUTOCODE
METER............................. 57
PRODIGY AUTOCODE
MONITOR SYST ............. 57
PRODIGY LANCETS ......... 57
PRODIGY LANCING
DEVICE ........................... 57
PRODIGY NO CODING ..... 50
PRODIGY POCKET METER
.......................................... 57
PRODIGY TWIST TOP
LANCET .......................... 57
PRODIGY VOICE GLUCOSE
METER ............................ 57
PRODRIN ............................ 18
PROFERRIN-FORTE .......... 95
PROFILNINE....................... 33
progesterone ......................... 75
progesterone micronized ...... 75
PROGLYCEM ..................... 50
PROGRAF ........................... 13
PROLASTIN-C .................... 44
PROLENSA ......................... 81
PROLEUKIN ....................... 71
PROLIA ............................... 73
PROMACTA........................ 33
promethazine .................. 83, 84
promethazine vc ................... 84
promethazine vc-codeine...... 84
promethazine-codeine .......... 84
promethazine-dm .................. 84
promethazine-phenylephcodeine ............................. 84
promethegan ......................... 84
PROMETRIUM ................... 75
PROMISEB .......................... 37
PROMISEB COMPLETE .... 36
propafenone .......................... 27
propantheline ........................ 65
proparacaine ......................... 81
propranolol ........................... 31
propranolol-hydrochlorothiazid
.......................................... 31
propylthiouracil .................... 47
PROQUAD (PF) .................. 72
PRO-RED AC (W/
DEXCHLORPHENIR) .... 84
PROSCAR............................ 87
PROSTIN E2 ........................ 76
PROSTIN VR PEDIATRIC . 88
protamine.............................. 33
PROTECT IRON ................. 95
PROTHELIAL ..................... 46
PROTONIX.......................... 69
PROTOPIC........................... 38
protriptyline .......................... 26
PROVENTIL HFA............... 86
PROVERA ........................... 75
PROVIDA DHA .................. 95
PROVIDA OB ...................... 95
PROVIGIL ........................... 26
PROZAC .............................. 26
PROZAC WEEKLY ............ 26
pruclair.................................. 38
prudoxin................................ 38
prumyx.................................. 38
prutect ................................... 38
PSORCON............................ 43
PULMICORT ....................... 86
PULMICORT FLEXHALER
.......................................... 86
pulmosal ............................... 86
PULMOZYME ..................... 86
PURALOR CI ...................... 95
PUREFE OB PLUS .............. 95
PUREFE PLUS .................... 95
purevit dualfe plus ................ 95
PURIXAN ............................ 13
PYLERA .............................. 69
pyrazinamide .......................... 7
PYRIDIUM .......................... 88
pyridostigmine bromide ....... 19
Q
Q-CARE RX Q4 ................... 46
QNASL................................. 86
QUADRACEL (PF) ............. 72
QUALAQUIN ........................ 7
QUARTETTE ...................... 79
quasense................................ 79
quazepam .............................. 26
QUDEXY XR....................... 16
QUESTRAN......................... 34
QUESTRAN LIGHT ............ 34
quetiapine ............................. 26
QUFLORA PEDIATRIC ..... 95
QUFLORA PEDIATRIC
DROPS ............................. 95
QUILLICHEW ER ............... 26
QUILLIVANT XR ............... 26
quinapril................................ 31
quinapril-hydrochlorothiazide
.......................................... 31
quinidine gluconate .............. 27
quinidine sulfate ................... 27
quinine sulfate ........................ 7
QUINTET AC ...................... 50
QUINTET BLOOD
123
QUIT 2.................................. 45
QUIT 4.................................. 45
QUTENZA ........................... 38
QVAR ................................... 86
R
rabeprazole ........................... 69
RADIOGARDASE............... 45
RAGWITEK .........................72
raloxifene .............................. 73
ramipril ................................. 31
RANEXA ............................. 35
ranitidine hcl ......................... 69
RAPAFLO ............................ 87
RAPAMUNE ........................ 13
RAPIVAB............................... 3
RASUVO (PF)...................... 74
RAVICTI .............................. 45
RAYOS................................. 47
RAZADYNE ........................ 18
RAZADYNE ER .................. 18
rea lo 39 ................................ 38
rea lo 40 ................................ 38
react ...................................... 79
REBETOL ............................ 70
REBIF (WITH ALBUMIN) .70
REBIF REBIDOSE ..............70
REBIF TITRATION PACK .71
RECLAST ............................ 45
reclipsen (28) ........................ 79
RECOMBINATE ................. 33
RECOMBIVAX HB (PF)..... 72
RECTIV ................................ 67
REFUAH PLUS ................... 50
REFUAH PLUS GLUCOSE
MONITOR ....................... 57
REGLAN .............................. 67
regonol .................................. 19
REGRANEX ........................ 38
relador pak ............................ 40
relador pak plus .................... 40
RELAGARD ........................ 76
relcof c .................................. 84
RELENZA DISKHALER ...... 3
RELIAMED LANCET ......... 57
RELIAMED MINI LANCING
DEVICE ........................... 57
RELIAMED SAFETY SEAL
LANCETS ........................ 58
RELION CONFIRM ............ 58
RELION CONFIRM-MICRO
.......................................... 50
RELION MICRO GLUCOSE
MONITOR ....................... 58
RELION NEEDLES ............ 58
RELION PEN NEEDLES .... 58
RELION PRIME METER ... 58
RELION PRIME TEST
STRIPS ............................. 50
RELION THIN LANCETS.. 58
RELION ULTRA THIN PLUS
LANCETS ........................ 58
RELISTOR ........................... 67
relnate dha ............................ 95
RELPAX .............................. 18
REMERON .......................... 26
REMERON SOLTAB .......... 26
remeven ................................ 38
REMICADE ......................... 67
REMODULIN ...................... 31
RENACIDIN ........................ 88
RENAGEL ........................... 67
renal caps .............................. 95
RENAL VITAMIN .............. 95
rena-vite ................................ 95
rena-vite rx ........................... 95
reno caps ............................... 95
RENVELA ........................... 67
repaglinide ............................ 63
repaglinide-metformin .......... 63
REPATHA SURECLICK .... 34
REPATHA SYRINGE ......... 34
reprexain ............................... 21
REQUIP ............................... 17
REQUIP XL ......................... 17
RESCRIPTOR ........................ 3
RESCULA............................ 82
reserpine ............................... 31
RESPA-AR........................... 84
RESTASIS ........................... 81
RESTORIL ........................... 26
RETIN-A .............................. 39
RETIN-A MICRO ................ 39
RETIN-A MICRO PUMP .... 39
RETISERT ........................... 82
RETROVIR ............................ 3
REVATIO ............................ 86
REVEAL BLOOD GLUCOSE
METER ............................ 58
REVEAL TEST STRIP ........ 50
REVESTA ............................ 95
REVIA .................................. 23
REVLIMID .......................... 71
revonto .................................. 19
REXULTI ............................. 26
REYATAZ ............................. 3
REZIRA................................ 84
RHEUMATREX .................. 13
RIASTAP ............................. 33
ribasphere ............................. 71
ribasphere ribapak ................ 71
ribavirin ................................ 71
RIDAURA ............................ 74
rifabutin .................................. 7
RIFADIN ................................ 7
RIFAMATE............................ 7
rifampin .................................. 7
RIFATER ............................... 7
RIGHT STEP PRENATAL
VITAMINS ...................... 95
RIGHTEST GD500
RIGHTEST GL300 LANCETS
.......................................... 58
RIGHTEST GM550 SYSTEM
.......................................... 58
RIGHTEST GS550 TEST
STRIPS ............................. 50
RILUTEK ............................. 45
riluzole .................................. 45
rimantadine ............................. 3
ringers ................................... 44
RIOMET ............................... 63
risacal-d ................................ 95
risedronate ...................... 45, 73
RISPERDAL ........................ 26
RISPERDAL CONSTA ....... 26
RISPERDAL M-TAB .......... 26
risperidone ............................ 26
RITALIN .............................. 26
RITALIN LA ........................ 26
RITUXAN ............................ 13
rivastigmine .......................... 18
rivastigmine tartrate .............. 18
RIXUBIS .............................. 33
rizatriptan.............................. 18
R-NATAL OB ...................... 96
ROBAXIN ............................ 19
124
ROBAXIN-750..................... 19
ROBINUL ............................ 65
ROBINUL FORTE ............... 65
ROCALTROL ...................... 62
ropinirole ..............................17
rosadan ..................................39
ROSANIL .............................39
ROSULA .............................. 39
rosula cleansing cloths ..........39
rosuvastatin ........................... 34
ROTARIX ............................ 72
ROTATEQ VACCINE ......... 72
ROWASA ............................. 67
roweepra ............................... 16
ROXICODONE .................... 21
ROZEREM ........................... 26
RUCONEST ......................... 86
rulavite dha ........................... 96
RYANODEX ........................ 19
rydex ..................................... 84
RYNODERM ....................... 38
RYTARY .............................. 17
RYTHMOL .......................... 27
RYTHMOL SR .................... 28
S
SABRIL ................................ 16
SAFETY LANCETS ............58
SAFETY SEAL LANCETS .58
SAFETY-LET LANCETS ...58
SAFYRAL ............................ 79
SAIZEN ................................70
SAIZEN CLICK.EASY ....... 70
salacyn ..................................36
SALAGEN .....................45, 46
SALEX .................................36
salicylic acid .........................36
salicylic acid er-ceramides ...36
SALKERA ............................36
salsalate.................................23
salvax ....................................36
SALVAX DUO PLUS .........36
SAMSCA..............................62
SANCUSO ...........................67
SANDIMMUNE...................13
SANDOSTATIN ..................13
SANDOSTATIN LAR
DEPOT .............................13
SANTYL ..............................43
SAPHRIS (BLACK
CHERRY) ........................ 26
SARAFEM ........................... 26
SAVAYSA ........................... 33
SAVELLA ............................ 74
scalacort ................................ 43
SCALACORT DK ............... 43
SEASONIQUE ..................... 79
seb-prev ................................ 36
seconal sodium ..................... 26
SECTRAL ............................ 31
SEEBRI NEOHALER.......... 86
SELECT-OB ........................ 96
SELECT-OB + DHA ........... 96
selegiline hcl ......................... 17
selenium sulfide.................... 36
SELRX ................................. 36
SELZENTRY ......................... 3
SEMPREX-D ....................... 84
se-natal 19 ............................ 96
se-natal 19 (with docusate)... 96
SENSIPAR ........................... 62
SEREVENT DISKUS .......... 86
SEROQUEL ......................... 26
SEROQUEL XR .................. 26
SEROSTIM .......................... 70
sertraline ............................... 26
se-tan dha.............................. 96
se-tan plus ............................. 96
setlakin ................................. 79
sf 46
sf 5000 plus .......................... 46
sharobel ................................ 75
SHOHL'S MODIFIED ......... 88
SIGNIFOR ........................... 13
SIGNIFOR LAR .................. 13
sildenafil ............................... 86
SILENOR ............................. 26
SILVADENE ....................... 36
silver nitrate .......................... 38
silver nitrate applicators ....... 38
silver sulfadiazine................. 36
SIMBRINZA ........................ 82
SIMPONI ............................. 74
SIMPONI ARIA ................... 74
SIMULECT .......................... 13
simvastatin............................ 34
SINEMET............................. 17
SINEMET CR ...................... 17
SINGLE-LET ....................... 58
SINGULAIR ........................ 86
SINOGRAFIN ...................... 45
sirolimus ............................... 13
SIRTURO ............................... 7
SITAVIG ................................ 3
SIVEXTRO ............................ 7
SKELAXIN .......................... 19
SKLICE ................................ 43
SKYLA ................................. 74
SMART SENSE LANCETS 58
SMART SENSE
MONITORING SYSTEM 58
SMART SENSE TEST
STRIPS ............................. 50
SMARTDIABETES
VANTAGE ....................... 58
SMARTEST EJECT............. 58
SMARTEST LANCET ........ 58
SMARTEST PERSONA
STARTER ........................ 58
SMARTEST PRONTO
STARTER ........................ 58
SMARTEST PROTEGE ...... 58
SMARTEST TEST............... 50
SNAP INSULIN PUMP
CONTROLLER................ 58
SNAP INSULIN PUMPINFUSION SET ............... 58
sodium chlor 0.9% bacteriostat
.......................................... 45
sodium chloride .............. 86, 89
sodium chloride 0.45 % ........ 89
sodium chloride 0.9 % .......... 45
SODIUM CHLORIDE 0.9 %
.......................................... 45
sodium chloride 3 % ............. 89
sodium chloride 5 % ............. 89
sodium citrate-citric acid ...... 88
SODIUM EDECRIN ............ 31
sodium ferric gluconat-sucrose
.......................................... 45
sodium fluoride............... 46, 96
sodium phenylbutyrate ......... 45
sodium phosphate ................. 89
sodium polystyrene sulfonate
.......................................... 67
SODIUM POLYSTYRENE
SULFONATE ................... 68
125
SOFT TOUCH LANCETS... 58
SOFTGELS MULTIVITA,B,D,E,K,ZN .................. 96
SOLARAZE ......................... 38
SOLIRIS ............................... 45
SOLODYN ............................. 9
SOLTAMOX ........................ 13
SOLUS V2 AUDIBLE
METER............................. 58
SOLUS V2 LANCETS.........58
SOLUS V2 LANCING
DEVICE ...........................58
SOLUS V2 TEST STRIPS ...50
SOMA...................................19
SOMATULINE DEPOT ...... 13
SOMAVERT ........................ 62
sonafine................................. 38
SONATA .............................. 26
SOOLANTRA ...................... 39
SORBITOL........................... 44
SORBITOL-MANNITOL .... 44
SORIATANE ....................... 36
SORILUX ............................. 36
sotalol ................................... 28
SOTALOL ............................ 28
sotalol af ............................... 28
SOTYLIZE ........................... 28
SOVALDI............................... 3
SPECTRACEF ....................... 5
spinosad ................................ 43
SPIRIVA RESPIMAT .......... 86
SPIRIVA WITH
HANDIHALER ................ 86
spironolactone....................... 31
spironolacton-hydrochlorothiaz
.......................................... 31
SPORANOX........................... 2
SPORANOX PULSEPAK ..... 2
sprintec (28) .......................... 79
SPRITAM ............................. 16
SPRIX ................................... 23
SPRYCEL............................. 13
sps ......................................... 68
sronyx ................................... 79
ss 10-2 ................................... 39
ssd ......................................... 36
SSKI ..................................... 47
sss 10-5 ................................. 39
STALEVO 100 ..................... 17
STALEVO 125..................... 17
STALEVO 150..................... 17
STALEVO 200..................... 17
STALEVO 50....................... 17
STALEVO 75....................... 17
STARLIX ............................. 63
stavudine................................. 3
STELARA ............................ 36
STERILANCE TL................ 58
STIMATE............................. 62
STIOLTO RESPIMAT ........ 86
STIVARGA.......................... 13
STRATTERA ....................... 26
STRENSIQ ........................... 62
STREPTOMYCIN ................. 7
stress formula ....................... 96
stress formula with iron ........ 96
stress formula with iron(sulf)96
STRIANT ............................. 62
STRIBILD .............................. 3
STRIVERDI RESPIMAT .... 86
STROMECTOL ..................... 7
strong iodine ......................... 90
STROVITE FORTE ............. 96
STROVITE ONE ................. 96
SUBOXONE ........................ 23
SUBSYS ............................... 21
SUCRAID ............................ 68
sucralfate .............................. 69
SULAR ................................. 31
sulfacetamide sodium ..... 36, 83
sulfacetamide sodium (acne) 41
sulfacetamide sodium-sulfur 39
sulfacetamide sod-sulfur-urea
.......................................... 39
sulfacetamide-prednisolone.. 83
sulfacetamide-sulfur-cleansr23
.......................................... 39
sulfacleanse 8-4 .................... 40
sulfact na-sul-avobnz-otn-ocsa
.......................................... 40
sulfadiazine............................. 9
sulfamethoxazole-trimethoprim
............................................ 9
SULFAMYLON................... 41
sulfasalazine ......................... 68
sulfatrim ................................. 9
sulindac................................. 23
SUMADAN.......................... 40
SUMADAN XLT ................. 40
sumatriptan ........................... 18
sumatriptan succinate ........... 18
SUMAVEL DOSEPRO ....... 18
SUMAXIN ........................... 40
SUMAXIN CP ..................... 40
SUMAXIN TS ...................... 40
SUPER THIN LANCETS .... 58
SUPERVITE ........................ 96
SUPERVITE (EC) ................ 96
SUPRAX ................................ 5
SUPREP BOWEL PREP KIT
.......................................... 68
SURE COMFORT LANCETS
.......................................... 58
SURE COMFORT LANCING
PEN .................................. 58
SURE COMFORT PEN
NEEDLE .......................... 58
SURE-FINE PEN NEEDLES
.......................................... 58
SUREFLEX LANCING
DEVICE ........................... 59
SURE-LANCE ..................... 59
SURE-PEN LANCING
DEVICE ........................... 59
SURE-TEST EASYPLUS
MINI ................................. 50
SURE-TEST EASYPLUS
MINI METER .................. 59
SURE-TOUCH LANCET .... 59
SURFAXIN .......................... 86
SURGUARD2 SAFETY ...... 59
SURMONTIL....................... 26
SURVANTA ........................ 45
SUSTIVA ............................... 3
SUTENT............................... 13
SWABFLUSH ...................... 45
syeda ..................................... 79
SYLATRON ......................... 71
SYLVANT ........................... 13
SYMAX DUOTAB .............. 65
symax fastabs ....................... 65
symax-sl................................ 65
symax-sr ............................... 65
SYMBICORT....................... 86
SYMBYAX .......................... 27
SYMLINPEN 120 ................ 63
SYMLINPEN 60 .................. 63
126
SYNAGIS ............................... 3
SYNALAR ........................... 43
SYNALAR CREAM KIT .... 43
SYNALAR OINTMENT KIT
.......................................... 43
SYNALAR TS...................... 43
SYNALGOS-DC .................. 21
SYNAREL............................ 62
SYNERA .............................. 40
SYNJARDY ......................... 64
SYNRIBO............................. 13
SYNTHROID ....................... 64
SYPRINE ............................. 45
syrex sodium chloride 0.9% .45
T
T
SLIM.................................59
SLIM G4 ...........................59
TABLOID.............................13
TACLONEX.........................36
tacrolimus .......................13, 38
TAFINLAR ..........................13
TAGRISSO...........................14
TAKE ACTION ...................79
TALTZ AUTOINJECTOR ..36
TALTZ AUTOINJECTOR (2
PACK) ..............................36
TALTZ AUTOINJECTOR (3
PACK) ..............................36
TALTZ SYRINGE ...............36
TALTZ SYRINGE (2 PACK)
..........................................36
TALTZ SYRINGE (3 PACK)
..........................................36
TALWIN ..............................23
TAMIFLU ..............................3
tamoxifen ..............................14
tamsulosin .............................87
TANDEM PLUS ..................96
TANZEUM...........................64
TAPAZOLE .........................47
TARCEVA ...........................14
TARGRETIN .......................14
tarina fe 1/20 (28) .................79
TARKA ................................31
taron forte .............................96
taron-c dha ............................96
taron-prex prenatal-dha ........96
TASIGNA.............................14
TASMAR ............................. 17
TAXOTERE ......................... 14
TAZICEF ............................... 5
TAZORAC ........................... 40
TECENTRIQ........................ 14
TECFIDERA ........................ 71
TECHLITE LANCETS ........ 59
TECHLITE PEN NEEDLE .. 59
TECHNIVIE........................... 3
TEFLARO .............................. 5
TEGRETOL ......................... 16
TEGRETOL XR ................... 16
TEKTURNA ........................ 31
TEKTURNA HCT ............... 31
TELCARE BGM .................. 59
TELCARE BLOOD
GLUCOSE KIT ................ 59
TELCARE TEST STRIPS ... 50
telmisartan ............................ 31
telmisartan-amlodipine ......... 31
telmisartan-hydrochlorothiazid
.......................................... 31
temazepam ............................ 27
TEMODAR .......................... 14
TEMOVATE ........................ 43
temozolomide ....................... 14
tencon ................................... 21
TENEX ................................. 31
TENIPOSIDE ....................... 14
TENIVAC (PF) .................... 72
TENORETIC 100................. 31
TENORETIC 50................... 31
TENORMIN ......................... 31
TERAZOL 3 ......................... 76
TERAZOL 7 ......................... 76
terazosin ............................... 31
terbinafine hcl ......................... 2
terbutaline ............................. 87
terconazole ........................... 76
TERSI FOAM ...................... 36
TESSALON PERLES .......... 84
TEST N'GO BLOOD
GLUCOSE SYSTEM....... 59
TEST N'GO TEST ............... 50
TESTIM ............................... 62
TESTONE CIK .................... 62
TESTOPEL .......................... 62
testosterone ........................... 62
TESTOSTERONE ............... 62
testosterone cypionate .......... 62
testosterone enanthate........... 62
TESTRED ............................ 62
TETANUS,DIPHTHERIA
TOX PED(PF) .................. 72
TETANUS-DIPHTHERIA
TOXOIDS-TD .................. 72
tetcaine.................................. 81
tetrabenazine ......................... 18
tetracaine hcl......................... 81
tetracaine hcl (pf).................. 81
tetracycline ............................. 9
TETRAVISC ........................ 81
TETRAVISC FORTE .......... 81
TEXACORT......................... 43
TEXAVITE LQ .................... 96
THALOMID ......................... 14
THEO-24 .............................. 87
theochron .............................. 87
theophylline .......................... 87
thermazene............................ 36
THIOLA ............................... 45
thioridazine ........................... 27
thiotepa ................................. 14
thiothixene ............................ 27
THRIVITE RX ..................... 96
thrivite-19 ............................. 96
THYMOGLOBULIN ........... 72
THYROLAR-1 ..................... 64
THYROLAR-1/2 .................. 64
THYROLAR-1/4 .................. 64
THYROLAR-2 ..................... 64
THYROLAR-3 ..................... 64
tiagabine ............................... 16
TIAZAC ............................... 31
ticlopidine ............................. 33
TIGAN.................................. 68
TIKOSYN ............................ 28
tilia fe.................................... 79
timolol maleate ............... 31, 80
TIMOPTIC ........................... 80
TIMOPTIC OCUDOSE (PF)
.......................................... 80
TIMOPTIC-XE .................... 80
TINDAMAX .......................... 7
tinidazole ................................ 7
TIROSINT ............................ 64
TITUS NEEDLE .................. 59
TIVICAY................................ 3
127
TIVORBEX .......................... 23
tizanidine .............................. 19
tl gard rx ............................... 96
tl g-fol os............................... 96
tl icon .................................... 96
tl-hem 150 ............................. 96
TOBI ....................................... 7
TOBI PODHALER ................ 7
TOBRADEX ........................ 82
TOBRADEX ST ................... 82
tobramycin ............................ 80
tobramycin in 0.225 % nacl .... 7
tobramycin in 0.9 % nacl ........ 7
tobramycin sulfate .................. 7
tobramycin-dexamethasone .. 82
TOBREX .............................. 80
TODAY CONTRACEPTIVE
SPONGE........................... 76
TOFRANIL .......................... 27
TOLAK................................. 38
tolazamide............................. 64
tolbutamide ........................... 64
tolcapone............................... 17
tolmetin ................................. 23
tolterodine ............................. 87
TOPAMAX .......................... 16
TOPCARE UNIVERSAL1
LANCET .......................... 59
TOPICORT........................... 43
topiramate ............................. 16
TOPIRAMATE .................... 16
toposar .................................. 14
topotecan............................... 14
TOPROL XL ........................ 31
TORISEL .............................. 14
torsemide .............................. 31
TOUJEO SOLOSTAR ......... 61
TOVIAZ ............................... 87
TRACLEER ......................... 87
TRADJENTA ....................... 64
tramadol ................................ 23
TRAMADOL ....................... 23
tramadol-acetaminophen ...... 23
trandolapril ........................... 31
trandolapril-verapamil .......... 31
tranexamic acid ............... 33, 76
TRANSDERM-SCOP .......... 68
TRANXENE T-TAB ............ 27
tranylcypromine .................... 27
TRAVATAN Z .................... 82
travoprost (benzalkonium) ... 82
trazodone .............................. 27
TREANDA ........................... 14
TRECATOR ........................... 7
TRELSTAR .......................... 14
TRESIBA FLEXTOUCH U100 .................................... 61
TRESIBA FLEXTOUCH U200 .................................... 61
tretinoin ................................ 40
tretinoin (chemotherapy) ...... 14
tretinoin microspheres .......... 40
TRETIN-X ........................... 40
TRETIN-X CREAM KIT..... 40
TRETTEN ............................ 33
TREXALL............................ 14
TREXIMET.......................... 18
TREZIX ................................ 21
TRIACETIN ......................... 41
triamcinolone acetonide . 43, 46
triamterene-hydrochlorothiazid
.......................................... 31
trianex ................................... 43
triazolam ............................... 27
TRIBENZOR ....................... 31
TRICARE ............................. 96
TRICARE PRENATAL DHA
ONE.................................. 96
TRICARE PRENATAL WITH
DHA ................................. 96
tricitrates ............................... 88
tricon..................................... 96
TRICOR ............................... 34
triderm .................................. 43
TRIESENCE (PF) ................ 47
tri-estarylla ........................... 79
TRIFERIC ............................ 96
trifluoperazine ...................... 27
trifluridine............................. 80
trigels-f forte ......................... 96
TRIGLIDE ........................... 34
trihexyphenidyl..................... 17
tri-legest fe............................ 79
TRILEPTAL......................... 16
tri-linyah ............................... 79
TRILIPIX ............................. 34
tri-lo-estarylla ....................... 79
tri-lo-marzia.......................... 79
tri-lo-sprintec ........................ 79
trilyte with flavor packets ..... 68
trimethobenzamide ............... 68
trimethoprim ......................... 10
trimipramine ......................... 27
trinatal gt............................... 96
trinatal rx 1 ........................... 96
trinate .................................... 96
trinessa (28) .......................... 79
trinessa lo.............................. 79
TRI-NORINYL (28)............. 79
TRINTELLIX ....................... 27
TRIOSTAT ........................... 64
triphrocaps ............................ 96
TRIPLE DYE ....................... 41
tri-previfem (28) ................... 79
TRISENOX .......................... 14
tri-sprintec (28) ..................... 79
TRISTART DHA ................. 96
tri-tabs dha ............................ 96
TRIUMEQ .............................. 3
triveen-duo dha ..................... 96
TRI-VI-FLOR ...................... 96
tri-vit with fluoride and iron . 96
tri-vitamin with fluoride ....... 96
trivora (28) ............................ 79
TRIZIVIR ............................... 3
TROKENDI XR ................... 16
TROPAZONE LOTION ...... 38
tropicamide ........................... 81
trospium ................................ 87
TRUE METRIX GLUCOSE
METER ............................ 59
TRUE METRIX GLUCOSE
TEST STRIP..................... 50
TRUE2GO BLOOD
TRUEDRAW LANCING
DEVICE ........................... 59
TRUEPLUS LANCETS ....... 59
TRUERESULT BLOOD
GLUCOSE SYSTM ......... 59
TRUETEST TEST STRIPS . 50
TRUETRACK BLOOD
TRUETRACK SMART
SYSTEM .......................... 59
TRUETRACK TEST ........... 50
TRULICITY ......................... 64
128
TRUMENBA ........................ 72
TRUSOPT ............................ 82
trust natal dha ....................... 96
TRUVADA.............................3
TUDORZA PRESSAIR .......87
tusnel c ..................................84
TUSNEL PEDIATRIC ......... 84
TUSSICAPS ......................... 84
tussigon ................................. 84
TUSSIONEX PENNKINETIC
ER ..................................... 84
TUZISTRA XR .................... 84
TWINRIX (PF) ..................... 72
TWYNSTA........................... 31
TYBOST................................. 3
TYGACIL............................... 7
TYKERB .............................. 14
TYLENOL-CODEINE #3 ....21
TYLENOL-CODEINE #4 ....21
TYSABRI ............................. 18
TYVASO .............................. 87
TYVASO REFILL KIT ........87
TYVASO STARTER KIT ...87
TYZEKA ................................3
TYZINE ................................46
U
UCERIS ................................68
UDAMIN SP ........................ 96
ULESFIA .............................. 43
ULORIC ............................... 73
ULTICARE PEN NEEDLE .59
ULTI-LANCE ......................59
ULTILET BASIC LANCETS
..........................................59
ULTILET CLASSIC
LANCETS ........................ 59
ULTILET LANCETS ........... 59
ULTILET PEN NEEDLE..... 59
ULTILET SAFETY
LANCETS ........................ 59
ULTIMA MONITOR ........... 59
ULTIMA TEST STRIPS ...... 50
ultimatecare one.................... 96
ultimatecare one nf ............... 97
ULTRA THIN LANCETS ...59
ULTRA THIN PLUS
LANCETS ........................ 59
ULTRA TLC LANCETS .....59
ULTRACET .........................23
ULTRALANCE LANCETS 59
ULTRAM ............................. 23
ULTRAM ER ....................... 23
ULTRASAL-ER................... 36
ULTRA-THIN II INS PEN
NEEDLES ........................ 59
ULTRATRAK...................... 50
ULTRATRAK GLUCOSE
METER ............................ 59
ULTRATRAK ULTIMATE50,
59
ULTRAVATE ...................... 43
ULTRAVATE X .................. 43
umecta .................................. 38
UMECTA PD ....................... 38
UNASYN ............................... 8
UNIFINE PENTIPS ............. 59
UNIFINE PENTIPS PLUS .. 60
UNILET COMFORTOUCH
LANCET .......................... 60
UNILET EXCELITE II
LANCET .......................... 60
UNILET EXCELITE
LANCET .......................... 60
UNILET GP LANCET......... 60
UNILET LANCET............... 60
UNISTIK 2 DEVICE ........... 60
UNISTIK 2 NORMAL
LANCET,DEVICE .......... 60
UNISTIK 3 ........................... 60
UNISTIK 3 EXTRA LANCET
.......................................... 60
UNISTIK CZT LANCET..... 60
UNISTIK SAFETY .............. 60
UNISTIK TOUCH LANCETS
.......................................... 60
UNISTRIP1 TEST STRIP ... 50
unithroid ............................... 64
UNITUXIN .......................... 14
UNIVERSAL 1 LANCETS . 60
UPTRAVI............................. 31
ur n-c .................................... 88
URAMAXIN ........................ 38
URAMAXIN GT.................. 38
uramit mb ............................. 88
urea ....................................... 38
urea nail stick ....................... 38
urea-hyaluronate sodium ...... 38
URECHOLINE .................... 87
ure-k...................................... 38
URELLE ............................... 88
uretron d-s............................. 88
URIBEL................................ 88
urimar-t ................................. 88
urin ds ................................... 88
UROCIT-K 10 ...................... 88
UROCIT-K 15 ...................... 88
UROCIT-K 5 ........................ 88
urogesic-blue ........................ 88
uro-l ...................................... 88
urolet mb............................... 88
uro-mp .................................. 88
urophen mb ........................... 88
UROQID-ACID NO.2.......... 88
UROXATRAL ..................... 87
URSO 250 ............................ 68
URSO FORTE...................... 68
ursodiol ................................. 68
uryl........................................ 88
ustell ..................................... 88
UTA ...................................... 88
UTIBRON NEOHALER ...... 87
utira-c.................................... 88
UTOPIC................................ 38
UVADEX ............................. 38
V
VAGIFEM ............................ 75
vaginal contraceptive foam .. 76
valacyclovir ............................ 3
VALCHLOR ........................ 38
VALCYTE ............................. 3
valganciclovir ......................... 3
VALIUM .............................. 27
valproate sodium .................. 16
valproic acid ......................... 16
valproic acid (as sodium salt)
.......................................... 16
valsartan................................ 31
valsartan-hydrochlorothiazide
.......................................... 31
VALTREX ............................. 3
VANATOL LQ .................... 21
VANCOCIN ......................... 10
vancomycin .......................... 10
VANCOMYCIN IN
DEXTROSE 5 % .............. 10
vandazole .............................. 76
VANOS ................................ 43
129
VANOXIDE-HC .................. 40
VAQTA (PF) ........................ 72
VARIVAX (PF)....................72
VARIZIG ..............................72
VARUBI ...............................68
VASCEPA ............................34
VASERETIC ........................31
VASHE WOUND THERAPY
..........................................44
VASOSTRICT ..................... 62
VASOTEC ............................ 31
v-c forte ................................ 97
VCF CONTRACEPTIVE
FILM................................. 76
VCF CONTRACEPTIVE GEL
.......................................... 76
VECAMYL .......................... 35
VECTIBIX ........................... 14
VECTICAL .......................... 36
VELCADE ........................... 14
veletri .................................... 31
velivet triphasic regimen (28)
.......................................... 79
VELPHORO ......................... 68
VELTASSA .......................... 68
VELTIN ................................ 40
vemavite-prx-2 ..................... 97
VENCLEXTA ...................... 14
VENCLEXTA STARTING
PACK ............................... 14
venlafaxine ........................... 27
VENOFER ............................ 97
VENTAVIS .......................... 87
VENTOLIN HFA ................. 87
VERAMYST ........................ 87
verapamil .............................. 31
VERDESO ............................ 43
verdrocet ............................... 21
VEREGEN ........................... 38
VERELAN ........................... 31
VERELAN PM ..................... 31
veripred 20 ............................ 47
VERSACLOZ....................... 27
VESICARE........................... 87
vestura (28) ........................... 79
VEXOL................................. 82
VFEND ................................... 2
VFEND IV.............................. 2
VGO 20 ................................ 60
VGO 30 ................................ 60
VGO 40 ................................ 60
VIBATIV ............................. 10
VIBERZI .............................. 68
VIBRAMYCIN ...................... 9
vic-forte ................................ 97
vicodin .................................. 21
vicodin es.............................. 21
vicodin hp ............................. 21
VICTOZA 2-PAK ................ 64
VICTOZA 3-PAK ................ 64
VIDAZA............................... 14
VIDEX 2 GRAM PEDIATRIC
............................................ 3
VIDEX EC ............................. 3
VIEKIRA PAK ...................... 3
vienva ................................... 79
VIGAMOX........................... 80
VIIBRYD ............................. 27
VIMIZIM ............................. 62
VIMOVO ............................. 23
VIMPAT............................... 16
vinate care ............................ 97
vinate dha ............................. 97
VINATE DHA RF ............... 97
vinate ii ................................. 97
vinate m ................................ 97
vinate one ............................. 97
vinate ultra ............................ 97
vinblastine ............................ 14
vincasar pfs ........................... 14
vincristine ............................. 14
vinorelbine............................ 14
VIOKACE ............................ 68
viorele (28) ........................... 79
VIRACEPT ............................ 3
VIRAMUNE .......................... 3
VIRAMUNE XR .................... 3
VIRASAL............................. 36
VIRAZOLE ............................ 3
VIREAD ................................. 3
VIROPTIC ........................... 80
virt-advance .......................... 97
virt-c dha .............................. 97
VIRT-CAPS ......................... 97
virt-gard ................................ 97
virt-nate ................................ 97
virt-nate dha.......................... 97
virt-phos 250 neutral ............ 90
virt-pn ................................... 97
virt-pn dha ............................ 97
virt-pn plus ........................... 97
VIRTPREX .......................... 97
virtrate-2 ............................... 88
virtrate-3 ............................... 88
virtrate-k ............................... 88
virt-select .............................. 97
virtussin ac............................ 84
virtussin dac.......................... 84
virt-vite ................................. 97
virt-vite gt ............................. 97
VIRT-VITE PLUS ............... 97
VISTARIL ............................ 84
VISTOGARD ....................... 10
VISUDYNE.......................... 81
vit 3 ....................................... 97
vit b complex-folic acid ........ 97
VITA-BEE WITH C ............ 97
VITAFOL ............................. 97
VITAFOL FE+ (WITH
DOCUSATE) ................... 97
VITAFOL GUMMIES ......... 97
VITAFOL NANO ................ 97
VITAFOL ULTRA............... 97
vitafol-ob .............................. 97
VITAFOL-OB+DHA ........... 97
VITAFOL-ONE ................... 97
VITAL-D RX ....................... 97
VITAMED MD ONE RX .... 97
VITAMED MD PLUS RX ... 97
VITAMEDMD REDICHEW
RX .................................... 97
vitamin d3 ............................. 97
vitamin k ............................... 33
vitamin k1 ............................. 33
vitamins a,c,d and fluoride ... 97
VITAPEARL ........................ 97
VITA-RESPA....................... 97
VITEKTA ............................... 4
VITRASE ............................. 81
VITUZ .................................. 85
VIVA DHA .......................... 97
VIVELLE-DOT.................... 75
VIVITROL ........................... 23
VOGELXO ........................... 62
vol-care rx............................. 97
vol-nate ................................. 97
vol-plus ................................. 97
130
vol-tab rx .............................. 97
VOLTAREN......................... 23
VOLTAREN-XR .................. 23
VONVENDI ......................... 33
VORAXAZE ........................ 10
voriconazole ........................... 2
VOSPIRE ER ....................... 87
VOTRIENT .......................... 14
vp-ch plus ............................. 97
vp-ch-pnv .............................. 97
vp-ggr-b6 .............................. 97
vp-heme ob ...........................97
vp-heme one .........................97
VP-PNV-DHA ......................97
VPRIV ..................................62
vp-vite rx ..............................98
VRAYLAR ...........................27
VUSION ............................... 41
vyfemla (28) ......................... 79
VYTORIN 10-10 .................. 34
VYTORIN 10-20 .................. 34
VYTORIN 10-40 .................. 34
VYTORIN 10-80 .................. 34
VYVANSE ........................... 27
W
warfarin.................................33
water for irrigation, sterile ....45
WAVESENSE AMP ............60
WAVESENSE JAZZ...... 50, 60
WAVESENSE PRESTO 50, 60
WELCHOL........................... 34
WELLBUTRIN SR .............. 27
WELLBUTRIN XL .............. 27
wera (28) ............................... 79
westhroid .............................. 64
WIDE-SEAL DIAPHRAGM
.......................................... 74
WILATE ............................... 33
WP THYROID ..................... 64
wymzya fe ............................ 79
X
XALATAN ........................... 82
XALKORI ............................ 14
XANAX ................................ 27
XANAX XR ......................... 27
XARELTO ........................... 33
XARTEMIS XR ................... 21
XCLAIR ............................... 38
XELJANZ............................. 74
XELJANZ XR ...................... 74
XELODA ............................. 14
XENAZINE .......................... 18
XERESE ............................... 41
XGEVA ................................ 10
XIFAXAN .............................. 7
XIGDUO XR........................ 64
XODOL 10/300 .................... 21
XODOL 5/300 ...................... 22
XODOL 7.5/300 ................... 22
XOLAIR ............................... 87
XOLEGEL ........................... 41
XOPENEX ........................... 87
XOPENEX CONCENTRATE
.......................................... 87
XOPENEX HFA .................. 87
XTANDI............................... 14
xulane ................................... 76
XURIDEN ............................ 45
XYLOCAINE....................... 40
XYLOCAINE-EPINEPHRINE
.......................................... 40
XYLOCAINE-MPF ............. 40
xylon 10 ................................ 22
XYNTHA ............................. 33
XYNTHA SOLOFUSE ........ 33
XYREM ............................... 27
XYZAL ................................ 84
XYZBAC ............................. 98
Y
YALE SPINAL NEEDLE.... 60
YASMIN (28) ...................... 79
YAZ (28) .............................. 79
YERVOY ............................. 14
YONDELIS .......................... 14
Z
zafirlukast ............................. 87
zaleplon ................................ 27
ZALTRAP ............................ 14
zamicet ................................. 22
ZANABIN ............................ 38
ZANAFLEX ......................... 19
ZANOSAR ........................... 14
ZANTAC .............................. 69
zarah ..................................... 79
ZARONTIN ......................... 16
ZARXIO ............................... 70
zatean-ch............................... 98
zatean-pn dha........................ 98
zatean-pn plus ....................... 98
zavara.................................... 98
ZAVESCA............................ 62
ZEBETA ............................... 32
zebutal .................................. 22
ZEGERID ............................. 69
ZEGERID OTC .................... 69
ZELAPAR ............................ 17
ZELBORAF ......................... 14
ZEMAIRA ............................ 45
ZEMPLAR ........................... 62
zenatane ................................ 40
zenchent (28) ........................ 79
zenchent fe ............................ 79
zencia .................................... 40
ZENPEP ............................... 68
zenzedi .................................. 27
ZENZEDI ............................. 27
ZEPATIER ............................. 4
ZERBAXA ............................. 5
ZERIT ..................................... 4
ZESTORETIC ...................... 32
ZESTRIL .............................. 32
ZETIA .................................. 34
ZETONNA ........................... 87
ZEVALIN (Y-90) ................. 14
ZIAC ..................................... 32
ZIAGEN ................................. 4
ZIANA.................................. 40
zidovudine .............................. 4
ZINACEF ............................... 5
ZINACEF IN STERILE
WATER .............................. 5
ZINBRYTA .......................... 71
ZINECARD (AS HCL) ........ 10
zingiber ................................. 98
ZINGO.................................. 40
ZIOPTAN (PF) ..................... 82
ziprasidone hcl ...................... 27
ZIPSOR ................................ 23
ZIRGAN ............................... 80
ZITHRANOL ....................... 36
ZITHRANOL-RR ................ 36
ZITHROMAX ........................ 5
ZMAX .................................... 5
ZOCOR ................................ 34
ZODRYL AC 25 .................. 85
ZODRYL AC 30 .................. 85
ZODRYL AC 35 .................. 85
131
ZODRYL AC 40 .................. 85
ZODRYL AC 50 .................. 85
ZODRYL AC 60 .................. 85
ZODRYL AC 80 .................. 85
ZODRYL DAC 25 ............... 85
ZODRYL DAC 30 ............... 85
ZODRYL DAC 35 ............... 85
ZODRYL DAC 40 ............... 85
ZODRYL DAC 50 ............... 85
ZODRYL DAC 60 ............... 85
ZODRYL DAC 80 ............... 85
ZODRYL DEC 25 ................ 85
ZODRYL DEC 30 ................ 85
ZODRYL DEC 35 ................ 85
ZODRYL DEC 40 ................ 85
ZODRYL DEC 50 ................ 85
ZODRYL DEC 60 ................ 85
ZODRYL DEC 80 ................ 85
ZOFRAN (AS
HYDROCHLORIDE) ...... 68
ZOFRAN ODT ..................... 68
ZOHYDRO ER .................... 22
ZOLADEX ........................... 14
zoledronic acid...................... 62
zoledronic acid-mannitol-water
..........................................45
ZOLEDRONIC ACIDMANNITOL-WATER .....62
ZOLINZA .............................14
zolmitriptan...........................18
ZOLOFT ...............................27
zolpidem ...............................27
ZOLPIMIST .........................27
ZOMACTON .......................70
ZOMETA .............................62
ZOMIG .................................18
ZOMIG ZMT........................18
ZONALON ...........................38
ZONATUSS .........................85
ZONEGRAN ........................16
zonisamide ............................16
ZONTIVITY.........................33
ZORBTIVE ..........................70
ZORTRESS ..........................14
ZORVOLEX.........................23
ZOSTAVAX (PF) ................72
ZOSYN ...................................8
ZOSYN IN DEXTROSE (ISOOSM) ..................................8
zovia 1/35e (28).................... 79
zovia 1/50e (28).................... 79
ZOVIRAX ........................ 4, 41
Z-TUSS AC .......................... 85
ZUBSOLV ........................... 23
ZUPLENZ ............................ 68
ZUTRIPRO .......................... 85
ZYBAN ................................ 45
ZYCLARA ........................... 71
ZYDELIG ............................. 14
ZYFLO ................................. 87
ZYFLO CR ........................... 87
ZYKADIA ............................ 14
ZYLET ................................. 82
132
ZYLOPRIM .......................... 73
ZYMAXID ........................... 80
ZYPREXA ............................ 27
ZYPREXA RELPREVV ...... 27
ZYPREXA ZYDIS ............... 27
ZYTIGA ...............................14
ZYVOX ..................................7

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